Transportation Safety Board of Canada
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  AVIATION REPORTS - 2005 - A05H0002

The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

Aviation Investigation Report
Runway Overrun and Fire
Air France
Airbus A340-313 F-GLZQ
Toronto/Lester B. Pearson International
Airport, Ontario
02 August 2005

Report Number A05H0002

Synopsis

The Air France Airbus A340-313 aircraft (registration F-GLZQ, serial number 0289) departed Paris, France, at 1153 Coordinated Universal Time (UTC) as Air France Flight 358 on a scheduled flight to Toronto, Ontario, with 297 passengers and 12 crew members on board. Before departure, the flight crew members obtained their arrival weather forecast, which included the possibility of thunderstorms. While approaching Toronto, the flight crew members were advised of weather-related delays. On final approach, they were advised that the crew of an aircraft landing ahead of them had reported poor braking action, and Air France Flight 358's aircraft weather radar was displaying heavy precipitation encroaching on the runway from the northwest. At about 200 feet above the runway threshold, while on the instrument landing system approach to Runway 24L with autopilot and autothrust disconnected, the aircraft deviated above the glideslope and the groundspeed began to increase. The aircraft crossed the runway threshold about 40 feet above the glideslope.

During the flare, the aircraft travelled through an area of heavy rain, and visual contact with the runway environment was significantly reduced. There were numerous lightning strikes occurring, particularly at the far end of the runway. The aircraft touched down about 3800 feet down the runway, reverse thrust was selected about 12.8 seconds after landing, and full reverse was selected 16.4 seconds after touchdown. The aircraft was not able to stop on the 9000-foot runway and departed the far end at a groundspeed of about 80 knots. The aircraft stopped in a ravine at 2002 UTC (1602 eastern daylight time) and caught fire. All passengers and crew members were able to evacuate the aircraft before the fire reached the escape routes. A total of 2 crew members and 10 passengers were seriously injured during the crash and the ensuing evacuation.

Ce rapport est également disponible en français.

© Minister of Public Works and Government Services Canada 2007
    Cat. No. TU3-5/05-3E
    ISBN 978-0-662-47298-8

Transportation Safety Board of Canada - AVIATION REPORTS - 2005 - A05H0002
Transportation Safety Board of Canada
Symbol of the Government of Canada

  AVIATION REPORTS - 2005 - A05H0002

Table of Contents

  1. 1.0 Factual Information
    1. 1.1 History of the Flight
    2. 1.1.1 Departure
    3. 1.1.2 En Route
    4. 1.1.3 Descent and Approach
    5. 1.1.4 Landing
    6. 1.2 Injuries to Persons
    7. 1.3 Damage to the Aircraft
    8. 1.4 Other Damage
    9. 1.5 Personnel Information
    10. 1.5.1 Captain Information
    11. 1.5.2 First Officer Information
    12. 1.5.3 Cabin Crew Information
    13. 1.6 Aircraft Information
    14. 1.6.1 General Information
    15. 1.6.2 Aircraft Weight and Balance
    16. 1.6.3 Landing Speeds
    17. 1.6.4 Landing Distance Calculations
    18. 1.6.5 Stopping Performance
    19. 1.6.6 Aircraft Seats and Restraint Systems
    20. 1.6.7 Emergency Exits
    21. 1.6.8 Evacuation Escape Devices
    22. 1.6.9 Evacuation Alert System
    23. 1.6.10 Cabin Emergency Lighting
    24. 1.6.11 Public Adress System
    25. 1.6.12 Emergency Equipment
    26. 1.6.13 Automatic Flight System
    27. 1.6.14 Fuel Management and Monitoring
    28. 1.6.15 Weather Radar
    29. 1.6.16 Windshear Detection and Prediction
    30. 1.6.17 Aircraft Communications Addressing and Reporting System
    31. 1.6.18 Ground Spoilers
    32. 1.6.19 Brake System and Antiskid
    33. 1.6.20 Engine Controls
    34. 1.6.21 Rain Removal System
    35. 1.7 Meteorological Information
    36. 1.7.1 General
    37. 1.7.2 Graphic Area Forecasts
    38. 1.7.3 Aerodrome Forecasts
    39. 1.7.3.1 Toronto/Lester B. Pearson International Airport (CYYZ)
    40. 1.7.3.2 Niagara Falls International Airport, New York (KIAG)
    41. 1.7.3.3 Ottawa/Macdonald-Cartier International Airport (CYOW)
    42. 1.7.4 Aviation Routine Weather Reports
    43. 1.7.4.1 Toronto/Lester B. Pearson International Airport (CYYZ)
    44. 1.7.4.2 Ottawa/Macdonald-Cartier International Airport (CYOW)
    45. 1.7.4.3 Niagara Falls International Airport, New York (KIAG)
    46. 1.7.5 Significant Meteorological Information
    47. 1.7.6 Toronto/Lester B. Pearson International Airport (CYYZ) Wind Information
    48. 1.7.7 Recorded Rainfall Rates
    49. 1.7.8 Thunderstorms
    50. 1.7.9 Lightning
    51. 1.7.10 Red Alerts
    52. 1.7.11 Weather Conditions on the Ground
    53. 1.8 Aids to Navigation
    54. 1.8.1 Air Traffic Control Radar
    55. 1.8.2 Runway 24L Instrument Approach
    56. 1.9 Communications
    57. 1.9.1 General
    58. 1.9.2 External Communication
    59. 1.9.3 Internal Communication
    60. 1.10 Aerodrome Information
    61. 1.10.1 General
    62. 1.10.2 Airport Closure
    63. 1.10.3 Use of Runway 24L
    64. 1.10.4 Runway 24L Physical Description
    65. 1.10.5 Runway 24L Lighting and Markings
    66. 1.10.6 Water-Contaminated Runways
    67. 1.10.7 Hydroplaning
    68. 1.10.8 Runway Grooving
    69. 1.10.9 Runway Friction
    70. 1.10.10 Runway Certification Requirements
    71. 1.10.11 Runway End Safety Area Alternatives
    72. 1.10.12 Previous Runway Overrun Accident at Toronto
    73. 1.10.13 Automated Terminal Information System Broadcasts
    74. 1.10.14 Notice to Airmen
    75. 1.11 Flight Recorders
    76. 1.11.1 Cockpit Voice Recorder
    77. 1.11.2 Flight Data Recorder
    78. 1.11.2.1 General
    79. 1.11.2.2 Relevant Flight Data Recorder Information
    80. 1.12 Wreckage and Impact Information
    81. 1.12.1 Impact Damage
    82. 1.12.2 Fuselage
    83. 1.12.3 Wings
    84. 1.12.4 Stabilizers
    85. 1.12.5 Aircraft Engines and Auxiliary Power Unit
    86. 1.12.6 L2 Emergency Exit Door
    87. 1.12.7 Cockpit Seats
    88. 1.12.8 Cockpit
    89. 1.12.9 Tires and Brakes
    90. 1.13 Medical Information
    91. 1.14 Fire
    92. 1.14.1 Fire Initiation and Spread
    93. 1.14.2 Aircraft Rescue and Fire Fighting
    94. 1.14.3 Aircraft Familiarization Charts
    95. 1.15 Survival Aspects
    96. 1.15.1 General
    97. 1.15.2 Runway Excursion
    98. 1.15.3 The Evacuation
    99. 1.15.4 Use of Emergency Exits
    100. 1.15.5 Exit Slides
    101. 1.16 Tests and Research
    102. 1.16.1 Simulator Trials
    103. 1.16.2 Testing of Aircraft Brakes
    104. 1.16.3 Passenger Questionnaire
    105. 1.17 Organizational and Management Information
    106. 1.17.1 Air France Human Factors Training
    107. 1.17.2 Air France No-Blame Policy
    108. 1.17.3 Air France Airbus A340 Training
    109. 1.17.4 Air France Manuals, Policies, and Procedures
    110. 1.17.5 Flight Planning
    111. 1.17.6 Air France Procedures for Approach and Landing
    112. 1.17.7 Weather Radar
    113. 1.17.8 Air France Calculation of Landing Distance
    114. 1.17.9 Air France Policy on the Use of Reverse Thrust on Landing
    115. 1.17.10 Air France Procedures for Dealing with Windshear
    116. 1.17.11 Air France Information on Thunderstorms
    117. 1.17.12 Air France - Fatigue Management
    118. 1.17.13 Air France - Previous Safety Initiatives Concerning Landing Accidents
    119. 1.17.14 Emergency Procedures
    120. 1.17.15 Air France Differences from Airbus Manuals, Procedures, and Recommendations
    121. 1.17.16 Recurrent Emergency Training for Cabin Crew
    122. 1.18 Additional Information
    123. 1.18.1 Weather-Related Landing Occurrences - Internal Air France Investigations
    124. 1.18.2 Weather-Related Landing Occurrences - Other Operators
    125. 1.18.2.1 Hawaiian Airlines at Tahiti
    126. 1.18.2.2 American Airlines at Little Rock, Arkansas
    127. 1.18.2.3 Australian Transportation Safety Board
    128. 1.18.3 Study of Go-Around Events
    129. 1.18.4 Studies of Penetrations into Convective Weather
    130. 1.18.5 Research into Pilot Decision Making - Assessment of Risk and Weather
    131. 1.18.6 Flight Safety Foundation - Approach and Landing Accident Reduction Report
    132. 1.18.7 Research into Crew Management of Risk
    133. 1.18.8 Public Address System
    134. 1.18.9 Evacuation Alert System
    135. 1.18.10 Aircraft Emergency Lighting
    136. 1.18.11 Viewing Windows - Assessing Exterior Hazards in an Evacuation
    137. 1.18.12 Safety Briefing Cards for Passengers Travelling on the Flight Deck
    138. 1.18.13 Brace-for-Impact Commands
    139. 1.18.14 Provision of Safety Information - Recommended Brace-for-Impact Positions
    140. 1.18.15 Provision of Safety Information Regarding Carry-on Baggage
    141. 1.18.16 Provision of Safety Information During an Emergency - Language
    142. 1.18.17 Portable Emergency Equipment - Smoke Hoods and Megaphones
    143. 1.18.18 Dual-Lane Slides
    144. 1.19 Useful or Effective Investigation Techniques
    145. 1.19.1 Use of Flight Data Recorder and Cockpit Voice Recorder Animation as an Interview Tool
  2. 2.0 Analysis
    1. 2.1 Introduction
    2. 2.2 Aircraft
    3. 2.2.1 Emergency Exit Door L2
    4. 2.2.2 Aircraft Air Data Inertial Reference System - Wind Calculation
    5. 2.3 Airports
    6. 2.3.1 Runway End Safety Areas
    7. 2.3.2 Adequacy of Aircraft Rescue and Fire Fighting Aircraft Familiarization Charts (TP 11183)
    8. 2.3.3 Adequacy of Wind Information
    9. 2.4 Weather
    10. 2.4.1 Adequacy of Meteorological Data
    11. 2.4.2 Weather Information Provided by Air Traffic Control
    12. 2.5 Flight Operations
    13. 2.5.1 Crew Rest
    14. 2.5.2 The Accident Flight
    15. 2.5.3 Autopilot and Autothrust Use
    16. 2.5.4 Approaches in Convective Weather
    17. 2.5.5 Weather Information for Predicting Convective Weather
    18. 2.5.6 Landing on Contaminated Runways
    19. 2.5.7 Crew Resource Management / Threat and Error Management
    20. 2.5.8 Use of Rain Repellent
    21. 2.5.9 Captain-Only Missed Approach Call
    22. 2.5.10 Decision-Making Training for Difficult Approaches
    23. 2.6 Survivability
    24. 2.6.1 General
    25. 2.6.2 Fire
    26. 2.6.3 Aircraft Seats
    27. 2.6.4 Passenger Safety and Evacuation
    28. 2.6.4.1 Cockpit Safety Briefing Checklist
    29. 2.6.4.2 Pre-Landing Safety Briefings
    30. 2.6.4.3 Brace Position
    31. 2.6.4.4 Passenger Cabin and Baggage
    32. 2.6.4.5 Evacuation Slides
    33. 2.6.4.6 Cabin Crew Actions and Communications
  3. 3.0 Conclusions
    1. 3.1 Findings as to Causes and Contributing Factors
    2. 3.2 Findings as to Risk
    3. 3.3 Other Findings
  4. 4.0 Safety Action
    1. 4.1 Action Taken
    2. 4.1.1 Air France
    3. 4.1.1.1 Rain Repellent
    4. 4.1.1.2 Red Alert
    5. 4.1.1.3 Thunderstorms
    6. 4.1.1.4 Captain-Only Missed Approach
    7. 4.1.2 Transport Canada
    8. 4.1.3 Airbus
    9. 4.2 Action Required
    10. 4.2.1 Approaches into Convective Weather
    11. 4.2.2 Pilot Decision Making
    12. 4.2.3 Landing Distance Considerations
    13. 4.2.4 Runway End Safety Area Requirements
    14. 4.2.5 Carry-on Baggage
  5. Appendices
    1. Appendix A - Air France Runway 24L Approach Chart
    2. Appendix B - Airport Diagram - CYYZ
    3. Appendix C - Summary of Weather
    4. Appendix D - Airbus A330/A340 Location of Safety Equipment
    5. Appendix E - Runway End Safety Areas for Runway 24L
    6. Appendix F - Flight Data Recorder Values
    7. Appendix G - Landing Distance Required Chart - Contaminated
    8. Appendix H - Landing Distance Required Chart - Autobrake Full
    9. Appendix I - Glossary
  6. Photos
    1. Photo 1 - Weather at Threshold About Two Minutes Before Landing
    2. Photo 2 - AFR358 on Short Final
    3. Photo 3 - Weather Shortly After Landing
    4. Photo 4 - Accident Site
    5. Photo 5 - Aircraft Wreckage
    6. Photo 6 - Aircraft Stabilizers
    7. Photo 7 - Cockpit Seats
    8. Photo 8 - Aircraft Fire in Progress
    9. Photo 9 - Slide Training Device
  7. Figures
    1. Figure 1 - Landing Sequence Key Events
    2. Figure 2 - Aircraft Cabin and Exits
    3. Figure 3 - Weather Intensity Information Displayed to the Controller
    4. Figure 4 - Emergency Exits

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Transportation Safety Board of Canada - AVIATION REPORTS - 2005 - A05H0002
Transportation Safety Board of Canada
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  AVIATION REPORTS - 2005 - A05H0002

How This Report Is Organized

This report was prepared in accordance with Transportation Safety Board (TSB) standards for investigation reports. In keeping with these standards, the report is organized into the following main parts:

  • Part 1, Factual Information: Provides objective information that is pertinent to the understanding of the circumstances surrounding the occurrence.
  • Part 2, Analysis: Discusses and evaluates the factual information presented in Part 1 that the Board considered when formulating its conclusions and safety actions.
  • Part 3, Conclusions: Based on the analyses of the factual information, presents three categories of findings: findings as to causes and contributing factors to the occurrence; findings that expose risks that have the potential to degrade aviation safety, but that could not be shown to have played a direct role in the occurrence; and "other" findings that have the potential to enhance safety, or clarify issues of unresolved ambiguity or controversy.
  • Part 4, Safety Action: Based on the findings of the investigation, recommends safety actions required to be taken to eliminate or mitigate safety deficiencies, and records the main actions already taken or being taken by the stakeholders involved.

Available Formats

The report can be viewed in the following formats:

  • Paper.
  • PDF.

To obtain additional copies of the report, please contact

TSB Communications Division
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Canada

Telephone: (819) 994-3741
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Transportation Safety Board of Canada - AVIATION REPORTS - 2005 - A05H0002
Transportation Safety Board of Canada
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  AVIATION REPORTS - 2005 - A05H0002

Appendices

  1. Appendix A - Air France Runway 24L Approach Chart
  2. Appendix B - Airport Diagram - CYYZ
  3. Appendix C - Summary of Weather
  4. Appendix D - Airbus A330/A340 Location of Safety Equipment
  5. Appendix E - Runway End Safety Areas for Runway 24L
  6. Appendix F - Flight Data Recorder Values
  7. Appendix G - Landing Distance Required Chart - Contaminated
  8. Appendix H - Landing Distance Required Chart - Autobrake Full
  9. Appendix  I - Glossary

Appendix A - Air France Runway 24L Approach Chart

Appendix A - Air France Runway 24L Approach Chart

Appendix B - Airport Diagram - CYYZ

Appendix B - Airport Diagram - CYYZ

Appendix C - Summary of Weather

Time (UTC) Time Prior to Landing CYYZ Weather Information
Pre-Flight   TAF CYYZ 0539 z 06-06 280@10 P6SM SCT 40 FM 17Z VARIABLE@3 P6SM -SHRA BKN 30 PROB 30 17-22 2SM TSRA BKN CB 20 FM 22Z 300@8 P6SM BKN 30 RMK NEXT FCST BY 09Z
1444 5 hr 18 min METAR 14Z CYYZ Wind 360 @ 4 15SM 35 few 260 few 28/19 30.07 remark cu, ci
1608 3 hr 54 min AFR358 received ATIS Julliet (with 1600 CYYZ weather) via ACARS. ATIS JULLIET - 16Z 360@5 15SM SCT 45 SCT 120 SCT 260 30/20 30.04
1811 1 hr 51 min METAR CYYZ 18Z 120@2 8SM -TSRA SCT TCU 35 BKN 90 23/22 30.03 RECENT RAIN RMK TCU3 AC 3 CB ASOCTD
1913 0 hr 49 min AFR358 inquires if ATC has info about movement of system - believes it is going from north to south. ATC advises weather seems to be moving east
1915 0 hr 47 min AFR358 told of delays in Toronto - requests heading deviation due weather
1917 0 hr 45 min METAR CYYZ 19Z 220@07 4SM +TSRA BKN 05TCU BKN 080 24/23 A30.03 RMK TCU 6 AC1 CB ASSOCTD
1922 0 hr 40 min ATC advises AFR358 traffic is starting to move into Toronto
1933 0 hr 29 min AFR358 received ATIS Uniform via ACARS. AFR358 received METAR reports for KCLE, CYOW, and KIAG via ACARS.
1940 0 hr 22 min AFR358 asks ATC if weather is worsening in Toronto ATC advises able to send aircraft in now but not sure about later AFR358 asks to be kept advised as they may have to "deviate".
1944 0 hr 18 min AFR358 asks to be kept advised of worsening weather - ATC says will advise of weather.
1949 0 hr 13 min AFR358 requests deviation left to avoid weather.
1953 0 hr 09 min Controller asks JZA 8677 if they think they will get the field. Aircraft advises the weather is to the north and looking pretty bad.
1959 0 hr 03 min Tower advises AFR358 that: 2 previous aircraft reported braking action "poor" Wind instruments knocked out by thunderstorm - last report was 230 @ 7 Kt Lightning activity all around the airport
2000 0 hr 02 min Tower advises aircraft just landed reported wind at 290 @15G20kt Tower advises that RJ in front reported braking action "poor" until slowed below 60 Kt and clears AFR358 to land

Appendix D - Airbus A330/A340 Location of Safety Equipment

Appendix D - Airbus A330/A340 Location of Safety Equipment

Click to see larger image


Appendix E - Runway End Safety Areas for Runway 24L

Appendix E - Runway End Safety Areas for Runway 24L

Appendix F - Flight Data Recorder Values

Appendix F1 - Flight Data Recorder Values - Approach

Click to see larger image


Appendix F2 - Flight Data Recorder Values - Landing

Click to see larger image


Appendix F3 - Flight Data Recorder Values - Landing Spoilers

Click to see larger image


Appendix F4 - Flight Data Recorder Values - Landing Brake System

Click to see larger image



Appendix G - Landing Distance Required Chart - Contaminated

 

This document does not exist in English.

Appendix G - Landing Distance Required Chart - Contaminated


Appendix H - Landing Distance Required Chart - Autobrake Full

This document does not exist in English.

Appendix H - Landing Distance Required Chart - Autobrake Full

Appendix I - Glossary

AAIB Air Accidents Investigation Branch (United Kingdom)
ACARS aircraft communications addressing and reporting system
ACC Area Control Centre
ADIRS air data inertial reference system
AFM aircraft flight manual
AFR358 Air France Flight 358
agl above ground level
ALAR approach and landing accident reduction
AMC aeromedical centre
AP autopilot
APU auxiliary power unit
ARFF aircraft rescue and fire fighting
ASDA accelerate-stop distance available
asl above sea level
ASR accident safety report
ATC air traffic control
A/THR autothrust
ATIS automated terminal information service
ATS air traffic services
ATSB Australian Transportation Safety Board
BEA Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile (France)
BKN broken cloud
BSCU brake and steering control unit
CAA Civil Aviation Authority
CAP CAA Publication
CARs Canadian Aviation Regulations
CAST Commercial Aviation Safety Team
CB cumulonimbus (clouds)
CLDN Canadian Lightning Detection Network
cm centimetres
CMAC-E Canadian Meteorological Aviation Centre - East
CRM crew resource management
CS certification standard
CVR cockpit voice recorder
CYOW Ottawa/Macdonald-Cartier International Airport, Ontario (ICAO code)
CYUL Montréal-Pierre Elliott Trudeau International Airport, Quebec (ICAO code)
CYYZ Toronto/Lester B. Pearson International Airport, Ontario (ICAO code)
dB decibels
DGAC Direction Générale de l'Aviation Civile (France)
DH decision height
DME distance measuring equipment
EASA European Aviation Safety Agency
ECAM electronic crew alerting and monitoring
ECU electronic control unit
EFC expected further clearance
EFIS electronic flight information system
ELT emergency locator transmitter
EMAS engineered material arresting system
EMS emergency services
EOC Emergency Operations Centre
EPSU emergency power supply unit
ETA estimated time of arrival
EXCDS extended computer display system
FAA Federal Aviation Administration (United States)
FAP flight attendant panel
FARs Federal Aviation Regulations
FCOM flight crew operations manual
FCTM flight crew training manual
FCU flight control unit
FDR flight data recorder
FL flight level
FMA flight mode annunciator
FMGS flight management and guidance system
FSF Flight Safety Foundation
g force
GA TRK go-around track (mode)
GEN.OPS manuel Généralités Opérations (part of the Air France MANEX related to general operating procedures)
GFA graphic area forecast
GPWS ground proximity warning system
GS groundspeed
G/S* glideslope track
G/S glideslope capture
GTAA Greater Toronto Airport Authority
HF high frequency
HMA hot-mix asphalt
hPa hectopascals
IATA International Air Transport Association
ICAO International Civil Aviation Organization
ILS instrument landing system
IMC instrument meteorological conditions
in. Hg inches of mercury
IRS inertial reference system
JAA Joint Aviation Authorities
JARs Joint Aviation Requirements
KBOS Boston-Logan International Airport, Massachusetts, United States
KCLE Cleveland-Hopkins International Airport, Ohio, United States
KEWR Newark International Airport, New Jersey, United States
kg kilogram
KIAG Niagara Falls International Airport, New York, United States
KIAS knots indicated airspeed
KJFK John F. Kennedy International Airport, New York, New York, United States
km kilometres
KORD Chicago O'Hare International Airport, Illinois, United States
LAW landing weight
LFPG Paris-Foissy-Charles-de-Gaulle Airport, France (IATA Code)
LGCIU landing gear control interface unit
LLWAS low-level windshear alert system
LOC localizer track
LOC* localizer capture
LOFT line-oriented flight training
LOSA line operations safety audit
m metres
M magnetic (degrees)
MAC manuel Aéronautique Complémentaire (manual providing general aeronautical information for Air France crews)
MAC mean aerodynamic chord
MANEX manuel d'exploitation (Air France operations manual)
MCC multi-crew coordination
MCDU multifunction control and display unit
MDA minimum descent altitude
METAR meteorological actual report (aviation routine weather report)
min minutes
MIT Massachusetts Institute of Technology
mm millimetres
MSC Meteorological Service of Canada
N1 engine compressor speed
N north
NARDS NAV CANADA auxiliary radar display system
NASA National Aeronautics and Space Administration
ND navigation display
nm nautical miles
NOTAM notice to airmen
NPA Notice of Proposed Amendments
NTO No Technical Objection
NTSB National Transportation Safety Board (United States)
NVM non-volatile memory
OFP operational flight plan
PA public address
PAPI precision approach path indicator
PDU processor display unit
PF pilot flying
PFD primary flight display
PNF pilot not flying
psi pounds per square inch
PSR primary surveillance radar
QRH quick reference handbook
RAMP radar modernization program
RDPS radar data processing system
RESA runway end safety area
rpm revolutions per minute
RSA runway safety area
RSit radar situational display
RVR runway visual range
SCT scattered cloud
SIGMET significant meteorological information
sm statute miles
SOPs standard operating procedures
SPECI special weather observation
SRS speed reference system
SSALS simplified short approach light system
STEADES safety trend evaluation, analysis, and data exchange system
T True (degrees)
TAF terminal aerodrome forecast (aerodrome forecast)
TAS true airspeed
TAT Touraine Air Transport
TC Transport Canada
TCAS traffic alert and collision avoidance system
TDWR terminal Doppler weather radar
TEM Threat and Error Management (model)
TEMPO termporary change
TODA take-off distance available
TOGA take-off and go-around
TORA take-off run available
TP Transport Publication
TP 11183 ERS Aircraft Crash Charts
TP 312E Aerodrome Standards and Recommended Practices
TRACON terminal radar approach control
TSB Transportation Safety Board of Canada
TSO Technical Standard Order
TU Technique Utilisation (manual part of the Air France MANEX related to technical standards)
UK United Kingdom
ULB underwater locator beacon
UTC Coordinated Universal Time
VAPP approach speed
VHF very high frequency
VLS landing speed
VMC visual meteorological conditions
VREF threshold crossing speed
W west
WADDS wind and altimeter digital display system
º degrees
ºC degrees Celsius
' minutes
" seconds

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1. See Glossary at Appendix I for all abbreviations and acronyms.

2. All times are UTC, unless otherwise indicated. Paris time is UTC + 2 hours. Toronto time is UTC - 4 hours.

3. See Section 1.7.10, Red Alerts, for an explanation of red alerts.

4. See Appendix G

5. See Section 1.17.8, Air France Calculation of Landing Distance, for a definition of landing distance.

6. Hereafter the term slide will be used to denote both slides and slide/rafts.

7. TAF Short request formats are not available in North America.

8. U. Ahlstrom, "Advanced Weather Displays for TRACON Controllers," The Journal of Air Traffic Control, 47(2), pp. 29-36.

9. The airport is at the centre of the circles.

10. An aircraft approach category is based on 1.3 times its stall speed. As an example, a Category D aircraft would have a speed 141 knots or more but less than 166 knots.

11. The take-off distance available is equal to the length of the runway plus the length of clearway. Runway 24L has a clearway of 1000 feet; a clearway is defined as the rectangular area over which an aircraft may make a portion of its initial climb to a specified height.

12. Standards are mandatory for airport certification unless a deviation has been approved.

13. Zulu is another term for UTC.

14. Driver's enhanced vision systems allow for increased visibility in darkness, fog, or smoke and can provide for enhanced navigation and tracking.

15. See Appendix G and Section 1.6.4.

16. See Appendix G and Section 1.6.4.

17. IATA, Go Around Events, Safety Trend Evaluation, Analysis and Data Exchange System (STEADES), 2005, Issue 1, pp. 9-14.

18. J. Orasanu and L. Martin, Errors in Aviation Decision Making: A Factor in Accidents and Incidents, presented at the 2nd Workshop on Human Error, Safety and Systems Development, April 1-2, 1998, Seattle, Washington, United States.

19. J. Orasanu, L. Martin, and J. Davison, "Cognitive and Contextual Factors in Aviation Accidents: Decision Errors," in E. Salas and G. Klein (eds.), Linking Expertise and Naturalistic Decision Making, Mahwah, New Jersey: Erlbaum, 2001, pp. 209-226.

20. D.R. Hunter, Risk Perception and Risk Tolerance in Aircraft Pilots, DOT/FAA/AM-02/17, United States Department of Transportation, FAA, Office of Aerospace Medicine, 2002.

21. P.D. Elgin and R.P. Thomas, An Integrated Decision-Making Model for Categorizing Weather Products and Decision Aids, NASA/TM-2004-212990, 2004.

22. R.M. McAdaragh, Toward a Concept of Operations for Aviation Weather Information Implementation in the Evolving National Airspace System, NASA/TM 2002-212141, 2002.

23. Flight Safety Foundation, "FSF ALAR Briefing Note 8.1 - Runway Excursions and Runway Overruns," Flight Safety Digest, August-November 2000.

24. Flight Safety Foundation, "FSF ALAR Briefing Note 1.1 - Human Factors," Flight Safety Digest, August-November 2000.

25. This study can be found on the TSB Website.

Transportation Safety Board of Canada - AVIATION REPORTS - 2005 - A05H0002
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  AVIATION REPORTS - 2005 - A05H0002

Appendix D - Airbus A330/A340 Location of Safety Equipment

Appendix D - Airbus A330/A340 Location of Safety Equipment

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Appendix F1 - Flight Data Recorder Values - Approach

Appendix F1 - Flight Data Recorder Values - Approach

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Appendix F2 - Flight Data Recorder Values - Landing

Appendix F2 - Flight Data Recorder Values - Landing

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Appendix F3 - Flight Data Recorder Values - Landing Spoilers

Appendix F3 - Flight Data Recorder Values - Landing Spoilers

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Appendix F4 - Flight Data Recorder Values - Landing Brake System

Appendix F4 - Flight Data Recorder Values - Landing Brake System

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1.0 Factual Information

1.1 History of the Flight

1.1.1 Departure

The Air France Airbus A340-313 aircraft (registration F-GLZQ, serial number 0289) departed Runway 09L at Paris-Foissy-Charles-de-Gaulle International Airport (LFPG),1 France, at 1153 Coordinated Universal Time (UTC)2 as Air France Flight 358 (AFR358) on a scheduled flight to the Toronto/Lester B. Pearson International Airport (CYYZ), Ontario, with 297 passengers and 12 crew members on board. Among their other pre-flight activities, the flight crew members obtained the weather forecast for their arrival, which included the possibility of thunderstorms. In anticipation of potential weather-related delays on arrival, an additional 3 metric tonnes (3000 kg) of fuel was uploaded to allow for an extra 23 minutes of holding time at Toronto.

The ground taxi and take-off were uneventful. The captain was designated as the pilot flying (PF) for the take-off and the first half of the flight. The first officer was the PF for the second half of the flight, including the approach and landing in CYYZ. The PF/PNF (pilot not flying) duties were exchanged to allow the captain to log a take-off on this flight. This exchange of duties occurred at 1617, and the crew switched from autopilot 1 to autopilot 2.

1.1.2 En Route

The flight plan for the ocean crossing was filed as follows: Track Bravo - Flight Level 350 (FL 350) at ocean entry waypoint. Climb to FL 360 at 40º west (W) longitude and climb to FL 370 at 60ºW. Before reaching the oceanic track system entry point, the aircraft received a clearance for track Alpha, one track north of the flight-planned track. The flight crew members received a new operational flight plan (OFP) via the aircraft communications addressing and reporting system (ACARS) from their company to reflect the track change. The flight followed this track with the restriction to not climb above FL 350 during the Atlantic crossing. The aircraft was eventually cleared to FL 360 at 1716, the highest altitude the aircraft reached on the flight.

At 1351, the flight crew members received requested weather information through the ACARS for potential emergency airports along their ocean-exit track over northeastern Canada.

At 1444, the flight crew members requested, via the ACARS, the aviation routine weather report (METAR) and aerodrome forecast (TAF) for their destination (CYYZ), and their alternate, Niagara Falls International Airport (KIAG), New York, United States. The 1400 METAR information was delivered to the aircraft, but a "TAF NIL" message was received instead of the requested TAF. This occurred because they had requested "TAF Short" even though both airports had only "TAF Long" available (see Section 1.6.17, Aircraft Communications Addressing and Reporting System). The 1400 METAR information for CYYZ and KIAG was unremarkable. There was no reported thunderstorm activity at either airport. At 1608, the flight crew received the 1600 automated terminal information service (ATIS) report for CYYZ indicating good ceiling and visibility with light winds. At 1617, the crew exchanged PF and PNF duties, corresponding to a change from autopilot 1 to autopilot 2. From this point forward, the first officer was the PF.

At 1750, AFR358 sent a message to Air France operations in CYYZ indicating an estimated time of arrival (ETA) of 1939. At 1753, AFR358 received a reply with information about the parking gate. The message did not indicate that there was a red alert3 in effect at CYYZ because it was not part of the station manager's procedures or requirements to inform the crew of red alerts. The crew was familiar with the red alert procedure, and there was information with respect to this procedure on the Air France approach charts.

At 1849, the flight crew members received requested METAR weather for KIAG, Ottawa/Macdonald-Cartier International Airport (CYOW), Ontario, their en route alternate, and Cleveland-Hopkins International Airport (KCLE), Ohio, United States. Thunderstorms were reported to the northwest of KIAG, moving southeast. There was no thunderstorm activity reported at either KCLE or CYOW. Again, they did not receive TAF information because of a "TAF Short" request. At this point, the estimated fuel remaining was approximately 12.2 tonnes. Fuel calculations by the crew indicated that there would be 8.7 tonnes remaining on arrival. With CYOW as a possible alternate, the crew calculated that 7.3 tonnes would be required to divert to CYOW, leaving 14 minutes of holding fuel at Toronto.

At 1903, the flight crew made initial contact with the Toronto Area Control Centre (ACC) - the Killaloe air traffic control (ATC) sector - and inquired about the CYYZ weather. The controller indicated that the flight crew would be kept informed about the weather.

At 1904, a message was sent to Air France operations in CYYZ indicating that, if a diversion was necessary, AFR358 would be going to CYOW. AFR358 did not inform ATC that they required a change in their alternate, nor were they required to do so at that time.

At 1913, a discussion between the flight crew and ATC on information regarding the movement of the active weather took place.

At 1915, AFR358 was given instructions to reduce to minimum speed due to landing delays at CYYZ. AFR358 requested and received vectors to avoid weather.

At 1917, the flight crew members received their requested METAR weather for CYYZ, which included information about thunderstorms and heavy rain.

1.1.3 Descent and Approach

At 1919, the crew briefed the windshear procedure. In the event windshear was encountered, the crew planned to conduct a missed approach.

At 1922, AFR358 was advised that traffic was starting to move into CYYZ and to expect further clearance at 1950. Considering the fuel status of AFR358, delaying to that time would be close to the maximum holding time. While on the heading of 040º, away from the airport, AFR358 reminded the controller twice that they were still headed away from the airport.

At 1928, AFR358 was cleared for a Simcoe 2 arrival procedure to Toronto. The fuel remaining was 9.3 tonnes; the aircraft was 137 nautical miles (nm) from destination.

At 1930, the crew reviewed the company's policy/procedure for when to declare minimum fuel. (See Section 1.17.5, Flight Planning, for a description of this procedure related to the occurrence flight.)

At 1933, the ATIS information broadcast indicated that CYYZ had reduced visibility in thunderstorms and heavy rain, and rapidly changing weather conditions; Runway 24L was the expected runway. Also, AFR358 received METARs via the ACARS for KCLE, CYOW, and KIAG. The decision was then made to use CYOW as the alternate, with six minutes of holding fuel available at Toronto.

Between 1936 and 1940, a briefing was conducted for the instrument landing system (ILS) approach to Runway 24L. The briefing did not include runway length or missed approach procedure. No runway distance calculations for a wet or contaminated runway were a part of this briefing.

At 1940, AFR358 requested an update on the CYYZ weather and were advised that aircraft were now able to go into CYYZ, but there was no prediction on the traffic flow situation. The flight crew requested to be kept advised of ongoing conditions, additional delays, and any worsening of the weather. At 1947, the chief purser was informed that, in the event that there was a diversion, the new destination would be CYOW. During that period, some aircraft on the same radio frequency were advising ATC that they were proceeding to alternate airports.

At 1949, AFR358 requested and received a deviation around weather on the approach. The CYYZ control tower frequency was on in the cockpit at this time and other aircraft were landing.

At 1953, the number one aircraft on approach (AFR358 was number three) was asked by ATC about their likelihood of being able to land. The reply was that the weather was to the north and looking pretty bad. It is not known if the flight crew of AFR358 heard that transmission. The two aircraft ahead of AFR358 landed successfully.

At 1953, the approach checklist was completed. Approach mode was selected, followed by flap one. The system page was manually selected from "Cruise" to "Circuit Breaker." A logo light fault was indicated on and cleared from the electronic crew alerting and monitoring (ECAM). The aircraft was established on the localizer at approximately 16 nm from the threshold.

During the initial descent, Flap 2 was selected and the landing gear was extended. The autopilot was disengaged followed by speedbrake retraction while descending through 4000 feet above sea level (asl). Flap 3 then flap full was selected, and, as the aircraft converged onto the glideslope through 3000 feet asl, the autopilot was re-engaged. The glideslope was intercepted approximately 8.7 nm from the threshold, with the aircraft stabilized and in landing configuration.

At 1958, AFR358 was at the approach speed on final approach. The previous aircraft had reported that braking action was poor; the tower wind instruments were not functioning because they were knocked off line during thunderstorm activity; the last wind available in the tower was 230º at 7 knots; and there was lightning all around the airport. The autobrake mode was reconfigured from autobrake low to autobrake medium, and callout commands for a go-around were reviewed.

At 1958, the crew wanted to complete the pre-landing checklist, but noted that the landing memo on the ECAM, which is part of the checklist, was not yet displayed. Although the ECAM items may be verified by the crew without having the checklist displayed, the crew delayed the pre-landing checklist. The challenge and response checklist had not been completed before landing although all the items in the checklist had been actioned as part of the normal cockpit flow. A Regional Jet landing ahead of AFR358 reported the wind as 290º at 15 to 20 knots, and that the braking action was poor until the aircraft was slowed below 60 knots.

Weather conditions during the remainder of the approach ranged from visual meteorological conditions (VMC) to instrument meteorological conditions (IMC) with flight in very dark clouds, turbulence, and heavy rain. AFR358 had visual contact with the ground when the aircraft was 2 to 3 nm from the runway. At an altitude between 1000 and 1500 feet above ground level (agl), about half of the runway was visible and at times part or all of the ramp area was clearly visible. The runway was covered with water, producing a shiny, glass-like surface. There was lightning on both sides and at the far end of the runway. The aircraft's weather radar showed heavy precipitation, with a red area encroaching on the runway from the northwest and another south of the runway. The flight crew obtained wind speed and direction from the aircraft's navigation display (ND), which indicated that there was a 70º to 90º crosswind from the right at 15 to 20 knots. The windshield wipers were turned on to SLOW at 4 nm from the runway and stayed on for the remainder of the flight.

The autopilot and autothrust were engaged while on the approach. While in automatic flight, the aircraft was stabilized on the localizer and glideslope, and was flying at the targeted speed of 140 knots. At 2001:18, as the aircraft passed through 323 feet agl, the PF disconnected the autopilot and two seconds later disengaged autothrust. The PF then increased engine thrust from about 42 per cent N1 (engine compressor speed) to about 82 per cent N1 because he sensed that the airspeed was decreasing and the aircraft was sinking. The flight data recorder (FDR) shows a small decrease in airspeed at that time. The aircraft then began to deviate above the glideslope. At about the same time, the wind direction shifted, changing from a 90º crosswind component to an increasing tailwind component of up to 10 knots.

1.1.4 Landing

The aircraft crossed the runway threshold about 40 feet above the glideslope. There were no callouts to indicate deviations from desired aircraft performance or trajectory. The aircraft entered an area of heavy rain, there were numerous lightning strikes occurring, and visual contact with the runway environment was severely reduced.

The PF began the flare when the aircraft was about 40 feet above the runway. From this point to touchdown, there were numerous and sometimes significant pitch inputs made on the PF side stick, and the aircraft levelled off at approximately 25 feet for a period of 2½ seconds. During this time, there were also regular and sometimes large inputs in roll on the PF side stick. Combined, these inputs would indicate that significant workload and attention were required on the part of the PF to control the aircraft. The crew began a progressive reduction in thrust from a 76 per cent N1 when the aircraft was at 50 feet, with the throttle levers reaching the idle position when the aircraft was about 20 feet above the runway.

Figure 1 - Landing sequence key events

Figure 1. Landing sequence key events

The aircraft touched down at 2001:53, approximately 3800 feet down the 9000-foot runway. On touchdown, the right main landing gear was slightly left of the runway centreline, and the aircraft was crabbed about six degrees to the right. The spoilers deployed automatically, as designed, after the main wheels contacted the runway. The flight crew immediately applied maximum manual braking and attempted to align the aircraft with the centreline. Idle reverse was selected 12.8 seconds after main gear touchdown, and full reverse was selected 16.4 seconds after main gear touchdown. Standard callouts to indicate spoiler and reverser deployment were not made by the PNF. The aircraft was not able to stop on the remaining runway. It departed the end of the runway at a groundspeed of approximately 80 knots and came to rest in a ravine. The aircraft left the runway at 2002:19.

As the flight landed, three or four bright orange flashes were observed from the control tower through the heavy rain. The tower supervisor was immediately advised and the crash alarm was triggered. The "1 Alpha" system alerts the emergency response agencies on and off the airport that an on-airport crash has occurred, and it initiates the complete mobilization of all available fire and rescue services.

The cabin crew ordered an evacuation within seconds of the aircraft stopping because fire was observed out the left side of the aircraft, and smoke was entering the cabin. There was no electrical power available on AFR358 and the radios would not operate in order to call the tower. After exiting his seat with difficulty, the first officer got a flashlight and went to the rear of the aircraft with the chief purser and one of the cabin attendants, checking to see if there was anyone left in the cabin or any of the lavatories. They returned to the front of the aircraft via the opposite aisle, confirming that the cabin was completely evacuated before they left the aircraft via the L1 door, from which they had to jump because the slide was only partially deployed. The first officer was the last person to exit the aircraft.

The captain also attempted to check the aircraft for passengers before exiting but was forced to turn back due to smoke as the first officer and the two others were finishing their search for remaining passengers on board. He left the aircraft via the R1 door, and had a difficult time exiting the aircraft because he had sustained back injuries.

All passengers and crew members were able to evacuate before the post-crash fire consumed most of the aircraft's fuselage. The accident happened at 2002 (1602 local time) during the hours of daylight and at a geographic location of latitude 43º39'20" N, longitude 79º37'27" W.

1.2 Injuries to Persons

  Crew Passengers Others Total
Fatal - - - -
Serious 2 10 - 12
Minor/None 10 287 - 297
Total 12 297 - 309

Thirty-three persons were taken to the hospital by ambulance. Of those, 21 were treated for minor injuries and released, and 12 (2 crew members and 10 passengers) were admitted with serious injuries. Nine persons received serious injuries as a result of the impact, and three persons received serious injuries during the evacuation. The two crew members who had suffered serious impact injuries were able to perform their emergency duties effectively. Passengers who incurred impact injuries were ambulatory during the evacuation. One of the cabin crew, seated in the same general area as the crew and passengers who incurred serious impact injuries, was not injured. This cabin crew's seat was aft-facing; the other seats were forward-facing.

1.3 Damage to the Aircraft

The aircraft was substantially damaged during the overrun, and was subsequently destroyed by the post-crash fire.

1.4 Other Damage

During the accident, there was no damage to the runway or blast pad at the exit end. Two runway end lights were destroyed as well as the last five bars of the Runway 06R approach lights (closest to the runway) (see Section 1.12, Wreckage and Impact Information).

1.5 Personnel Information

  Captain First Officer
Pilot Licence Airline Transport Airline Transport
Medical Expiry Date 31 January 2006 31 August 2005
Total Flying Hours 15 411 4834
Hours on Type 1788 2502
Hours Last 90 days 100 173
Hours on Type Last 90 Days 100 173
Hours on Duty Prior to Occurrence 10.5 10.5
Hours off Duty Prior to Work Period 12 days 12.5 hours

1.5.1 Captain Information

The captain flew his first solo in a glider on 01 December 1963. He joined the military service while waiting for a civilian job in aviation. In August 1973, the captain joined the French commuter airline Touraine Air Transport (TAT). Later, he joined Air Inter where he flew the Airbus A300. The captain became an Air France employee when Air Inter was merged with Air France in 1997.

When the captain joined Air France, he flew the Airbus A319, A320, and A321. With Air France, he was initially a captain and an instructor on the Airbus A320. He later applied for the long-haul service on the Airbus A340 and was accepted. Later, he was asked to become an instructor, but declined the offer because he wanted to learn more about the aircraft and the long-haul service first. He obtained his Airbus A340 rating in 2001.

The captain was considered a good and loyal employee, and there were no issues with his ability as a pilot or instructor. He had a good reputation for being easy to fly with and had a positive working relationship with cabin crew members. His priority in dealing with the aircraft crew was to have open communications and a relaxed, professional environment. He considers the training that he received and the training at Air France, in general, to be first rate.

The captain completed his last aviation medical exam on 07 July 2005 and held a Class 1 medical certificate, valid until 31 January 2006 and with the restriction that corrective lenses must be worn in flight. He completed his last line check on 08 October 2004. He completed his last pilot proficiency check on 19 April 2005, and had completed six take-offs and five landings on the Airbus A340 in the previous 90 days. The captain was qualified and certified in accordance with both company and regulatory requirements. The captain was working on a reduced flight schedule (see Section 1.13, Medical Information, for further details).

The captain's previous flight segment was on 18-19 July 2005, 12 days before the occurrence flight. On 18 July 2005, he was assigned as captain on AFR018 from LFPG to Newark International Airport (KEWR), New Jersey, United States. On that flight, AFR018 diverted to the Boston-Logan International Airport (KBOS), Massachusetts, United States, due to weather-related delays in KEWR. After a one-hour delay on the ground in KBOS, the aircraft departed for an uneventful flight to KEWR. On 19 July 2005, the captain flew the return flight to LFPG.

The captain relaxed and did nothing physically tiring during the weekend before the accident flight. He had a good sleep pattern and no problem with fatigue. On the day of the occurrence flight, the captain awoke at about 0630 local time. He lives in the south of France and took the train to LFPG, about a 2½-hour trip. The captain arrived at flight preparation about 2½ hours before the scheduled departure time.

About two hours before departure, he met with the first officer, whom he knew. He recognized the first officer from a previous simulator session, and expected that this would be a good flight. The captain did not know anyone from the assigned cabin crew, but struck up a good relationship immediately with the chief purser. Everyone seemed to be in a good mood, and the captain was pleased with the good communications among the crew.

1.5.2 First Officer Information

In March 1985, the first officer was hired by Air France as a cabin crew member. In 1986 and 1987, he attended a flight training school in the United States, following which he continued to gain pilot expertise in France by flying single-engine aircraft and studying flight theory in preparation for the Air France pilot selection process. He accumulated 800 flight hours and 100 simulator hours.

The first officer started pilot training with Air France in January 1991, but the training was cancelled at the end of February 1992 due to the Gulf War. He returned as a cabin crew member and was promoted to chief purser in 1995. He held this position for 1½ years. In 1996, the Air France pilot training program was restarted, and the first officer completed his multi-engine rating. He began working as a pilot with Air France on 01 April 1997. He flew as a first officer on the Airbus A319/A320/A321 series for a period of 3½ years and received his type rating on the Airbus A340 on 11 September 2001. He flew that aircraft type in long-haul operations as a first officer up until the accident flight.

The first officer was considered by Air France to be a solid and competent pilot, who had no problems on the line or during training. He had a good reputation with management and training pilots. Although he had not flown previously with the occurrence captain, they had met during a simulator session on 18 August 2000 when both pilots were working on the Airbus A320 fleet. On that occasion, the occurrence captain was acting as a check pilot, and the first officer was participating in a check flight in the simulator with another captain. This check flight was unsuccessful for both crew members due to a performance issue with the captain being tested. In accordance with Air France policy, the first officer received an additional training session and passed a check flight in the simulator on 20 August 2000 with a different check pilot. The first officer considered his training to be first rate, and the operating environment at Air France to be very professional and supportive.

The first officer completed his last aviation medical on 08 February 2005 and held a valid Class 1 medical certificate. He completed his last line check on 24 October 2004 and his last pilot proficiency check on 07 February 2005. Before the accident flight, he had conducted 8 take-offs and 6 landings on the Airbus A340 in the previous 90 days. In this period, he had also completed 2 take-offs and 2 landings in the Airbus A340 simulator. The first officer was qualified and certified in accordance with both company and regulatory requirements.

Before the occurrence flight, the first officer's previous flight as a crew member had been from LFPG to Atlanta, Georgia, United States, and return between 26 and 28 July 2005. Before the Atlanta flight, he had been on a three-week vacation. On the day before the occurrence, the first officer participated in a training session (as a first officer) for another Air France pilot who was undergoing captain's training.

The simulator session finished at about 2245 local time, and the first officer was home by about 2330. Although he could not fall asleep right away, he eventually slept well. He awoke at 0845 and felt well rested when he arrived at LFPG the next morning at about 1115 local time. He had had 12½ hours of off-duty time.

1.5.3 Cabin Crew Information

Cabin Crew Position Cabin Crew Experience at Air France
L1 (Chief Purser - Minimum Crew) 20 years
L2 (Forward Purser - Minimum Crew) 18 years
L3 (Minimum Crew) 8 years
L4 (Aft Purser - Minimum Crew) 13 years
R1 (Supplemental Crew) 5 years
R2 (Supplemental Crew) 10 years
R3 (Minimum Crew) 10 years
R4 (Minimum Crew) 5 years
Cabin Crew Seat 9 (Additional Crew) 5 weeks
Cabin Crew Seat 10 (Supplemental Crew) 4 years

There were 10 cabin crew on board; nine cabin crew plus one additional crew member, a crew member not yet qualified. In accordance with French regulatory requirements, all of the occurrence cabin crew were certified and qualified for their assigned duties.

Section JAR-OPS 1.990 of the European Joint Aviation Requirements (JARs) calls for "one cabin crew member for every 50, or fraction of 50, passenger seats installed on the same deck of the aeroplane." Cabin crew comprising the minimum crew must be qualified on the type of aircraft being operated. The minimum crew for AFR358 was six.

Cabin crew designated as members of the minimum crew were assigned to cabin crew stations L1 (chief purser), L2 (purser), L3, L4 (purser), R3 and R4, in accordance with company operating procedures. These cabin crew members were responsible for the safety of passengers. Cabin crew carried in addition to the required minimum crew are called supplemental crew and need not be qualified on the type of aircraft being operated.

There were three supplemental cabin crew members on the occurrence flight. They were assigned to cabin crew stations R1, R2, and cabin crew seat 10, located in the aft cabin between galleys 6 and 7. Supplemental cabin crew may perform duties related to passenger safety during normal operations and during emergency situations if directed to do so by a member of the minimum crew.

The additional cabin crew was on board for passenger service purposes only. She began working at Air France on 30 June 2005 and had completed four flights before the accident flight, her second flight on an Airbus A340. The additional crew member was assigned cabin crew seat 9, located adjacent to cabin crew seat 10. Under normal operating conditions, additional crew members cannot be assigned passenger safety-related duties. However, in an emergency situation, they may perform such duties if directed to do so by a member of the minimum crew (as may any other able-bodied passenger).

1.6 Aircraft Information

Manufacturer Airbus
Type and Model A340-313
Year of Manufacture 1999
Serial Number 0289
Certificate of Airworthiness Issued 07 September 1999
Total Airframe Time 28 426 hours
Engine Type (number of) CFM International 56-5C4 (4)
Maximum Allowable Take-off Weight 271 000 kg
Recommended Fuel Type(s) Jet A, Jet A1
Fuel Type Used Jet A1

1.6.1 General Information

The Airbus A340-313 is a wide-body (twin aisles), passenger, transport aircraft. The main deck was divided into three distinct areas: the flight deck, the flight crew rest area, and the passenger cabin. A rest area for cabin crew was located in the belly of the aircraft.

The flight deck accommodates two pilots, plus seats for two other occupants. The flight crew rest area, an enclosed compartment, is on the right side of the forward cabin, immediately aft of the flight deck. It contains two sleeping berths that can be converted to seats certified for take-off and landing. The compartment door is adjacent to the aisle leading to the flight deck and opens inward.

The aircraft passenger cabin was configured to accommodate 291 passenger seats. Passenger seats were placed 6 abreast in business class (forward cabin) and 8 abreast in economy (mid/aft cabin). There were 30 seats in business class (rows 1 to 6), 140 in the first section of economy (rows 14 to 31), and 121 in the second section of economy (rows 32 to 48). Overhead stowage compartments ran along the cabin sidewalls throughout the cabin seating area. Additional stowage compartments were fitted down the centre of the cabin, suspended from the ceiling. The stowage compartments were rated for 50 kg (110 pounds). Stowage compartment doors were designed to latch in the closed and open positions.

The aircraft has six cabin doors, three on the left side (L1, L2 and L4) and three on the right side (R1, R2, and R4), and two emergency exit doors (L3 and R3). The cabin doors are used as entrance and exit doors for the passengers and the crew. The aircraft cabin was equipped with eight cabin crew stations, one adjacent to each of the cabin doors/emergency exits. The cabin crew station at the L1 door included two cabin crew seats. From a seated position, cabin crews could reach certain emergency equipment, including the communication handset for the cabin interphone system and the public address (PA) system. Two additional cabin crew seats were located in the aft galley.

Figure 2 - Aircraft cabin and exits

Figure 2. Aircraft cabin and exits

1.6.2 Aircraft Weight and Balance

The FDR recorded value for the fuel weight at the time of landing was approximately 7500 kg and the zero fuel weight of the aircraft was 177 500 kg; therefore, the aircraft weight at the time of the landing was 185 000 kg. This landing weight value was verified by Airbus by studying the aerodynamic performance of the aircraft while on approach. The maximum landing weight is 190 000 kg, and the maximum zero fuel weight is 178 000 kg. The FDR recorded value for the aircraft centre of gravity at the time of the accident was 29.8 per cent MAC (mean aerodynamic chord), which is about mid-range of the allowable limits.

1.6.3 Landing Speeds

For a landing weight of 185 tonnes and flaps full, the certified runway threshold crossing speed (VREF) is 135 KIAS (knots indicated airspeed) and the approach speed (VAPP or target speed) is 140 KIAS.

1.6.4 Landing Distance Calculations

The information in the following three tables is derived from the Air France operations manual (manuel d'exploitation or MANEX).4 The calculated landing distance for a runway that is covered with less than 3 mm of water (wet runway), using the airport elevation for CYYZ, using autobrakes "low," and assuming no wind, full flaps, and without the use of thrust reversers, is 2196 m (7203 feet).

Autobrake Setting Dry Wet
Low 2185 m (7167 feet) 2196 m (7203 feet)
Medium 1652 m (5419 feet) 1777 m (5829 feet)

Derived from MANEX Chart TU04.01.64. 14A340-313 Full Flaps Landing Distance for Toronto (CYYZ) Pressure Altitude 500Feetasl - NoWind- VREF+5

MANEX Chart TU 04.01.64. 14 calls for a 21 per cent increase in the landing distance with a 10-knot tailwind. The table below contains the landing-distance values with the 10-knot tailwind correction applied. With a 10-knot tailwind, a wet runway, autobrakes "low," and without the use of thrust reversers, the calculated landing distance is 2657 m (8715 feet).

Autobrake Setting Dry Wet
Low 2644 m (8672 feet) 2657 m (8715 feet)
Medium 1999 m (6557 feet) 2150 m (7053 feet)

Derived from MANEX Chart TU 04.01.64. 14 A340-313 Full Flaps Landing Distance for Toronto (CYYZ) Pressure Altitude 500 Feet asl - 10-Knot Tailwind - V REF + 5

The calculated landing distance5 for Runway 24L at CYYZ for the conditions at the time of landing, assuming ¼-inch (approximately 6 to 7 mm) of water on the runway (contaminated), using manual braking, is summarized in the table below.

Wind No Reversers Using Four Reversers
0 2670 m (8780 feet) 2403 m (7883 feet)
5-knot tailwind 3071 m (10 075 feet) 2764 m (9068 feet)
10-knot tailwind 3471 m (11 388 feet) 3124 m (10 249 feet)

Derived from MANEX Chart TU04.02.50. 13A340-313 Full Flaps Landing Distance for Toronto (CYYZ) Pressure Altitude 500Feetasl, Manual Braking

The Airbus flight crew training manual (FCTM) states that passing over the runway threshold at 100 feet altitude rather than 50 feet will increase the total landing distance by approximately 950 feet (300 m).

1.6.5 Stopping Performance

Airbus was asked to provide information regarding normal thrust reverser deployment times and calculations of stopping distance for the Airbus A340-313 for a combination of actual and expected performance variables. The Airbus A340-313 aircraft flight manual (AFM) uses 5.1 seconds between main landing gear touchdown and thrust reverser selection, and 1 second for the thrust reversers to deploy when calculating stopping distance.

Using the environmental conditions for Runway 24L at the time of landing and the actual aircraft configuration of AFR358, stopping distances were calculated using the recorded FDR information. For the actual touchdown speed of 143 KIAS, with a 10-knot tailwind and the actual deployment of thrust reverser time of 16.4 seconds, the aircraft would have stopped in 6674 feet (2034 m) after touchdown. With full reverse thrust selected after touchdown in accordance with the AFM, the aircraft would have used 5938 feet (1809 m) of runway. With full reverse thrust selected after touchdown in accordance with the AFM and the aircraft touching down at the recommended speed, the aircraft would have used 5574 feet (1699 m) of runway. As noted in Section 1.1.4, the touchdown point was 3800 feet down the 9000-foot runway.

1.6.6 Aircraft Seats and Restraint Systems

The cockpit seats were certified to JAR 25.561. A review of the cockpit seat design documents indicated that these seats exceeded the minimum requirements of JAR 25.561. Both cockpit seats and the third occupant seat were column-mounted. The fourth occupant seat was a folding seat, attached to the rear partitioning wall on the right side of the flight deck. All of the seats in the flight deck were equipped with a four-point restraint harness.

The passenger and cabin crew seats were certified to JAR 25.561 (described as 9 g horizontally) and JAR 25.562 (described as 16 g horizontally). Passenger seats were equipped with a lap belt. The cabin crew seats and the seats in the flight crew rest area were equipped with three-point restraint harnesses. In accordance with JAR-OPS 1.730 (Subpart K), supplemental loop belts were provided for infants.

The certification basis for the accident aircraft was JAR 25, Change 13, effective on 05 October 1989. The Transport Canada (TC) Type Certificate Data Sheet identifies the certification basis for the Airbus A340-300 series as Airworthiness Manual, Chapter 525, Change 1, dated January 1987 (this is equivalent to JAR 25, Change 12), plus additional requirements with which Airbus elected to comply. The latter included JAR 25, Change 13, which introduced the Emergency Landing - Dynamic Conditions, Section 25.562, applicable to passenger seats.

TC has indicated that the current Canadian Aviation Regulations (CARs) require all aircraft seats to meet the requirements of Section 525.562, Emergency Landing - Dynamic Conditions. The European Aviation Safety Agency (EASA) certification standards (CS) require passenger seats to meet the requirements of CS 25.562. Even though Section 525.562 of the CARs is not harmonized with EASA's CS 25.562, the requirements of Section 525.562 of the CARs are presently applicable to all new applications for operation into Canada. At the present time, there is no movement to harmonize EASA's CS 25.562 with Section 525.562 of the CARs.

1.6.7 Emergency Exits

There were eight doors in the passenger cabin (see Section 1.6.1) that could be used as emergency exits. The six cabin doors (L1, L2, L4, R1, R2, and R4) are a Type A emergency exit and the two emergency exit doors (L3 and R3) are a Type I emergency exit. Type A and Type I doors were similar in construction and operation. Both were designed to be opened either from the interior or the exterior. The doors have a very slight, inward initial-opening movement and then open upward, outward, and forward. In the Airbus cabin crew operating manual, instructions for opening the doors from the interior state that, to open the door during NORMAL OPERATIONS, one must "Lift the door control handle fully up," which disengages two latches on the top of the door, thereby unlocking it.

Each door was equipped with a damper actuator system (door assist) comprising a damper and an emergency operation cylinder. The damper limits the travel of the door during normal operations, especially in windy conditions. During emergency operations, it acts as an actuator for automatic door opening. The damper and emergency operation cylinder are operated by compressed nitrogen stored in a cylinder equipped with a pressure gauge (commonly referred to as door pressure). The compressed nitrogen is released by an actuating device controlled by the slide arming lever. When the slide arming lever is in the ARMED position, as it is during landing, and the door operating handle is raised approximately 90º, the door assist engages and opens the door automatically. Each emergency exit door contained an observation window with a prismatic lens.

1.6.8 Evacuation Escape Devices

The aircraft was equipped with eight evacuation escape devices to facilitate rapid occupant egress in the event of an emergency: two single-lane slides at emergency exit doors L3 and R3, and six dual-lane slide/rafts6 at emergency exit doors L1, L2, L4, R1, R2, and R4. The slides on the occurrence aircraft were stowed in containers attached to the lower portion of each cabin door and were manufactured by Goodrich Corporation.

The deployment and inflation of the units are automatically initiated when the door is opened in the ARMED mode. As the door begins to open, two release pin lanyards detach the slide pack from the door and the outward movement of the door pulls the slide out of the aircraft; as the pack rolls out, the slide falls below the door sill and a firing lanyard activates. Primary gas is supplied to the slide and it begins to inflate. In the event that inflation does not start automatically, each slide is equipped with a red manual inflation handle. An intermediate tie device restrains the slide to approximately one-third of its extended length, to prevent it from inflating underneath the fuselage. When the slide becomes sufficiently pressurized, the intermediate tie releases and the slide is projected outward and downward to contact the ground. According to certification standards, the complete deployment sequence, from the door opening until the full inflation of the slide, is required to be within 16 seconds. However, the typical door opening/slide inflation time on the Airbus A340 is 8 seconds. There is no indication that the applicable certification standards were not met in this occurrence, except for the problem encountered with the L2 door.

1.6.9 Evacuation Alert System

Although not required by regulation, the aircraft was equipped with an evacuation alert system. An overhead panel in the flight deck contained:

  • an EVAC ON pushbutton, which, when pressed, activates red EVAC flashing lights in the flight deck and the cabin, and horns in the cabin at each door, signalling cabin crew to commence evacuating passengers;
  • a HORN OFF pushbutton, which, when pressed, silences the horn; and
  • a toggle switch with two positions: CAPT and CAPT & PURSER. When the toggle switch is in the CAPT position, the alert may be activated from the flight deck only. When the toggle switch is in the CAPT & PURSER position, the alert may be activated from either the flight deck or the cabin.

The flight attendant panel (FAP) located in the forward cabin included an EVAC/CMD pushbutton. When the pushbutton is depressed, red EVAC flashing lights are activated in the flight deck, signalling a request from the cabin for an evacuation. Emergency power for the evacuation alert system is provided by emergency batteries located in the avionics bay.

1.6.10 Cabin Emergency Lighting

The aircraft is equipped with an emergency lighting system that can be manually controlled from the flight deck and the FAP. The EMER EXIT LT toggle switch in the flight deck has three positions: ON - emergency lights, the EXIT signs, and the floor escape path marking illuminates; OFF; and ARM - the cabin emergency lighting automatically illuminates if the aircraft normal electrical power fails or if the EVAC ON pushbutton is activated.

The EMER EXIT LT switch is normally in the armed position and it has a mechanical latch that protects against operation of the switch from the ARM or ON position. The FAP has an EMER pushbutton that, when pressed, illuminates the emergency lights, the EXIT signs and the floor escape path marking system. The EMER pushbutton has a protective cover to prevent accidental operation. The emergency lighting system components include eight EXIT lights, one located over each EXIT doorframe, nine EXIT signs located in the exit areas ceiling, 25 emergency ceiling lights over the aisles; and a floor escape path marking system. This system includes EXIT markers and low-intensity lights located close to each exit at floor level and below passenger seats and electroluminescent light strips that illuminate cabin aisles.

Eight emergency power supply units (EPSUs), installed in the ceiling at each exit area, energize all the EXIT light signs and the floor proximity lights. In addition, the aircraft escape slides are equipped with an integral lighting system. The slide lights automatically illuminate when the slide deploys. Slide lights are powered by the EPSUs.

1.6.11 Public Adress System

In accordance with JAR-OPS 1.695 (Subpart K), the aircraft is equipped with a PA system. The system was certified as per the requirements of the United Kingdom (UK) Civil Aviation Authority (CAA) Specification 15. In the event of aircraft electrical power failure to the PA system, emergency power for the PA system is supplied by two batteries located in the avionics bay.

1.6.12 Emergency Equipment

The cabin was equipped with portable emerge Transportation Safety Board of Canada - AVIATION REPORTS - 2005 - A05H0002

Transportation Safety Board of Canada
Symbol of the Government of Canada

  AVIATION REPORTS - 2005 - A05H0002

1.11 Flight Recorders

1.11.1 Cockpit Voice Recorder

The cockpit voice recorder (CVR) was recovered from the accident site. The CVR was a Team model SSCVR, part number AP7123-2101 and serial number 170. This model of CVR is a solid-state recording device with a storage capacity of approximately two hours. An external examination of the CVR revealed significant heat exposure. The CVR identification plate was missing. The underwater locator beacon (ULB) or pinger bracket was damaged, and the ULB was missing. All relevant data were transcribed in full.

1.11.2 Flight Data Recorder

1.11.2.1 General

The solid-state FDR was a SFIM Industries model ESPAR, part number AP41116101, serial number 197. This particular FDR system on the Airbus A340 records over 500 parameters in a dataframe of 128 words per second, with a capacity of approximately 45 hours using data compression. An external examination of the FDR revealed significant heat exposure. Although the FDR was burned, it was possible to identify it from the name plate. There was no apparent impact damage and the ULB remained attached to its bracket.

A recorder of this type can be downloaded directly without disassembly if there is no damage to the memory module connectors. The module appeared to be intact; however, the memory module connector and the external interface cards exhibited heat damage. After disassembly, it was clear from the extent of the damage that a direct download would not be possible and that the memory cards would have to be removed for data recovery. Further disassembly of the unit was required to access the memory cards. There was considerable heat exposure to the internal circuitry and some connectors were melted. The module showed no signs of internal heat damage. The memory board was found to be in pristine condition.

Due to the extent of the observed damage to the units, it was deemed prudent to perform the repair work on the connector and its interface, as well as the downloading of the data with the assistance of France's Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile (BEA). The TSB team travelled to France for this delicate task. The memory modules were successfully downloaded using SFIM Industries software tools, and the full 45 hours of data were successfully recovered.

1.11.2.2 Relevant Flight Data Recorder Information

The winds encountered by the aircraft on short final were calculated using FDR recorded airspeed, groundspeed, heading, track, and angle-of-attack parameters. The calculated averaged winds were as follows:

Position FDR Recorded Winds Calculated Wind Tailwind Along Runway Axis Crosswind Across Runway Axis
Autothrust Disconnect   327ºM/15 knots -1 knot 15 knots
Threshold Crossing   004ºM/22 knots 12 knots 18 knots
Touchdown 330ºT/11 knots 005ºM/24 knots 12 knots 19 knots
Reverse Selection   360ºM/20 knots 10 knots 16 knots
End of Runway   355ºM/21 knots 10 knots 18 knots

FDR data revealed that the aircraft touched down at 2001:53 at a recorded computed airspeed of approximately 143 knots and a recorded groundspeed of approximately 150 knots. The aircraft touched down with a recorded normal g force of 1.2 g on a heading of 243ºM. Ground spoilers were armed for the approach and were fully deployed at 2001:58. The nose landing gear squat switch activated 5.75 seconds after touchdown. Manual brakes were applied approximately 2.5 seconds after touchdown, and the pedal displacement increased to 70º approximately five seconds after touchdown and remained at this level for the entire rollout. This corresponds to the maximum braking demand, 2500 pounds per square inch (psi) brake pressure. Reverse thrust was selected some 13 seconds after touchdown and the N1 parameters of the four engines stabilized at maximum reverse approximately five seconds later. The FDR stopped recording at 2002:23, four seconds after the aircraft left the runway.

FDR timings, longitudinal accelerometer data, and recorded groundspeed were used for various calculations to determine the touchdown point on the runway. It was determined that the touchdown point on Runway 24L was between 3800 feet and 3900 feet from the threshold. A comparison of the recorded longitudinal acceleration values and predicted longitudinal acceleration for conditions like those of the day of the accident provided by Airbus indicates a correlation with the performance expected for a runway contaminated by ¼-inch of water.

Review of the systems data did not show any failures that would have degraded the stopping performance of the aircraft.

1.12 Wreckage and Impact Information

1.12.1 Impact Damage

Tire marks from the left and right main gear, centre main gear, and nose gear were evident on the end of Runway 24L, the blast pad, and down the grass hill. The aircraft's left main landing gear inboard tires travelled directly over the survey button at the threshold of Runway 06R, indicating that the aircraft was just right of the Runway 24L centreline when it left the runway. Tire marks left on the blast pad and the grassy area indicate that the aircraft was yawed slightly to the right.

The aircraft crossed the service road, then Convair Drive, the landing gear, and two inboard engines leaving gouges in the pavement of Convair Drive. The aircraft knocked down the guard rail along the western side of Convair Drive and the fourth approach light tower. A small amount of aircraft debris was found in the field leading up to the edge of the ravine.

The aircraft came to rest in a ravine alongside Etobicoke Creek, on the extended centreline of Runway 24L. Most of the wreckage was contained within the radius of the aircraft, but there were several small components in the field before the ravine. The aircraft struck and destroyed the fifth set of approach lights as it entered the ravine. This set of lights comprised three pairs of frangible light towers, individually mounted on poured concrete pillars and arranged perpendicular to the runway centreline. The right landing gear struck and uprooted the inner concrete pillar of the right set of lights.

A post-crash fire consumed most of the upper portion of the main fuselage, vertical fin, and inner wing sections. The fire was intense and mainly limited to the fuselage. Fire singed and burned some of the surrounding vegetation, but did not spread beyond the circumference of the aircraft.

Photo 4 - Accident site

Photo 4. Accident site

The top of one of the passenger oxygen bottles exploded during the post-crash fire; the top was blown approximately 84 m (276 feet) across Etobicoke Creek.

1.12.2 Fuselage

Major break-up of the aircraft occurred only after it descended into the ravine. The nose cone sustained one minor puncture at the seven o'clock position. The upper part of the front fuselage, which contains the flight deck and the front passenger doors, was not significantly deformed. All windshield sections were intact and appeared undamaged. The upper fuselage and the interior aft of the L1 door were consumed by fire. The lower part of the front fuselage was severely dented.

Further aft, the front portion of the passenger cabin on the left side was consumed by fire. The forward cargo compartment, located beneath the cabin floor, retained its shape, although it was also consumed by fire. The forward cargo door was found in place and closed. Next to the cargo door, coincident with the location of the passenger oxygen cylinders, was a large hole in the fuselage wall that bore signs of explosive force. The surviving window frames were not distorted, indicating that this section of the fuselage did not experience undue stresses during the event.

There was distortion, resulting from the forces generated when the landing gear collapsed, transmitted through the integrating structure for the wing centre box. The condition of the keel beam, also located in this area, was impossible to assess due to fire damage and collapse of the surrounding structures. As the wreckage was being cleared from the site, the keel beam was inspected and found to have no pre-existing weaknesses.

Photo 5 - Aircraft wreckage

Photo 5. Aircraft wreckage

The rear portion of the fuselage on the left side was consumed by fire down to and including the cabin floor. Part of the left-side cabin wall was standing, though heavily damaged by the fire. Approximately four feet ahead of cabin door R4, there was a fold in the outer fuselage skin, indicating that the location was subjected to substantial bending forces during deceleration and break-up. The permanent deformation of the fuselage was very likely transmitted to the door frame. This would explain the difficulty the cabin crew experienced when attempting to open the R4 door. The door initially resisted opening and required two cabin crew members to push the door open. The rear cargo compartment door was found in place and closed, though almost burned through. The bulk cargo door was found on the ground, with the charred remains of the cargo spilling out of the door opening.

The unpressurized portion of the rear fuselage (aft of the rear pressure bulkhead) was less affected by fire than the rest of the fuselage. The collapsed and burned pieces of the vertical and horizontal stabilizers prevented an immediate assessment of the tail section of the fuselage, but it was later confirmed that there were no pre-accident deficiencies.

1.12.3 Wings

The left wing was found attached to the aircraft. The wing box rear spar-to-wing trailing edge inboard of the number 2 pylon was broken off. The wing bottom and top skins, including associated internal ribs, were sheared off, and the rear spar was found broken at rib one. The left main landing gear was attached to this piece of wing structure. The left wing had suffered heavy fire damage at the rear spar/rib one area. The top skin had melted in the vicinity of rib five. The inboard flap was found broken and separated from the wing structure.

All other left-wing trailing edge movable surfaces were identifiable. Four outboard spoiler panels were attached and in the closed position. Two inboard spoiler panels were located on the detached section of the wing. The aileron panels and the outboard flaps were attached and in the deployed position. The left-wing tip fence (winglet) was attached and basically undamaged. The leading edge movable surfaces (seven slats) were attached and in the deployed position. The leading edge of the left wing was heavily damaged in the vicinity of the number 2 pylon.

The right wing was attached to the aircraft. The wing box rear spar-to-wing trailing edge inboard of the number 3 pylon was broken off. The wing bottom and top skins, including associated internal ribs, were sheared off. The rear spar was found broken at rib one. The right main landing gear was broken and had separated from the wing. The right wing had sustained heavy fire damage at the rear spar between ribs one and five. The top skin and the internal wing structure had actually melted. The inboard flap was found broken and separated from the wing structure. All other movable leading and trailing edge surfaces (slats, ailerons, and flaps) were accounted for. The right-wing tip fence (winglet) was attached and basically undamaged. The right-wing leading edge was severely damaged at the number 3 pylon. Slat measurements were taken at three tracks, which confirmed that the slats had achieved full extension. The spoilers were in the retracted position.

1.12.4 Stabilizers

The trimmable horizontal stabilizer was still joined to the fuselage through the main box. The left-hand stabilizer was attached in position and had impact damage. The left-hand elevator was partially detached, but in position, and had impact damage. The right-hand stabilizer and elevator were attached in position and partially burned away. The tailplane tips, made of an aluminum alloy and part of the lightning protection system, were examined for evidence of a lightning strike; none was found. The vertical stabilizer was attached to the aircraft and in position. It was only after the intense fire that the lower half of the fin and rudder burned away and the rest collapsed to the right side. The rudder was separated from the fin box.

Photo 6 - Aircraft stabilizers

Photo 6. Aircraft stabilizers

1.12.5 Aircraft Engines and Auxiliary Power Unit

Examination of the four engines revealed no pre-impact anomalies. Organic material found on all booster inlet guide vanes of the four engines indicated that there was engine rotation during the impact sequence. Extension of the thrust reverser actuator pistons indicated that the thrust reverser doors were deployed during the impact sequence.

The electronic control unit (ECU) for each engine was removed and sent to General Electric for downloading of the non-volatile memory (NVM). Downloading was successfully completed and revealed no pre-impact faults with the engines. Two TSB investigators were in attendance.

The eight engine fire bottles were removed, and except for the forward bottle of the number three engine, all held their charge. The number three bottle was punctured in three areas. None of the squibs had fired.

The auxiliary power unit (APU) engine was in normal condition. There was no indication of pre-impact anomalies. The engine ducting was singed and wiring insulation was softened, consistent with excessive compartment temperatures from the post-impact fire.

The APU is equipped with a Halon fire-extinguishing bottle located forward and outside of the APU housing structure. The bottle was not physically damaged but had lost its charge; laboratory analysis revealed that the pressure relief valve was open. The squib had not fired.

1.12.6 L2 Emergency Exit Door

The pre-fire condition of all passenger and emergency exit doors was assessed, where possible. Some doors were significantly damaged by the fire. The emergency slide equipment was examined, with particular attention paid to passenger door L2, which was reported to have opened while the aircraft was decelerating. The L2 door, frame, and slide were moved to the TSB Engineering Laboratory for detailed examination and analysis.

Photos submitted by an evacuating passenger show that the L2 door was open and the emergency slide was not deployed. During the fire, the structure supporting the door had weakened and the door dropped to the ground. The initial examination at the site found the inner door handle in the up (open) position and the emergency handle armed. The rear slide release pin and cable was still attached to the door along with a piece of charred packboard. The girt bar, which secures the slide to the fuselage, was locked in the door frame sill. The door power assist had been activated, as the rupture disc in the actuator assembly had been punctured.

The interior face of the door was heavily damaged by the fire, the lining and insulation approximately 90 per cent consumed. A number of structural parts had melted. The connecting rod to the control handle mechanism was burned away. The hinge-arm door-open locking mechanism (hooks and overcentre device) was locked in the open position. The lifting mechanism was in the lifted position. The hooks, guides, stop fittings, and rollers were in good condition. There was no indication of binding, jamming or overstressing. The exterior of the door showed localized burn marks, the lower front corner was dented, and the adjacent inner structure was bent. The outside door handle was found in the closed position and was free to move by hand.

The various locking, lifting, and lowering mechanisms were cycled several times to test their function. The hinge-arm lock worked as designed. The locking shaft was moved back and forth, and the spring unit held the locking shaft in the overcentre position, as designed. Door unlocking can only be accomplished by the locking shaft rotation via the inner door handle. The weight balance torsion bar spring was disconnected and the door lifting mechanism was switched to the door lowered (closed) position. Attempts were then made to return the mechanism to the lift (open) position. It was impossible to rotate the lifting shaft because the overcentre travel blocked the movement, as designed. The door lifting (opening) can only be initiated by the inner door handle movement. The outer handle was tested and found functional. The emergency handle returned to the disarmed position when the outer handle was lifted, as designed.

The emergency evacuation slide was about 50 per cent consumed by the cabin fire. The slide had fallen into the cabin and was still in the folded configuration. The girt portion of the assembly (dark grey in colour) was not found. The packboard, which attaches the folded slide assembly to the door, was not found and is presumed to have been destroyed by fire. A small charred portion of the packboard, complete with the rear slide release pin and cable, was still attached to the door. The release pin was bent and discoloured from heat. The front slide release pin was found intact inside the cabin, an indication that it had released properly when the door opened. A force of approximately 80 pounds was needed to push the pin out of the rear attachment rail. The girt bar that attaches the slide to the door sill was found locked in place as it should be if it were used for an emergency evacuation.

1.12.7 Cockpit Seats

Both seats experienced high vertical forces during the event. The captain seat was displaced from its normal position. The floor of the seat base had fractured, allowing the chair to detach from the base. The nut attaching the centre screw to the bottom of the base on the first officer seat had pulled through the retainer. The force necessary to pull the nut through the retainer was mathematically calculated. It was determined that a vertical acceleration of a minimum of 16 g was likely reached before the seat broke. The seats were designed to withstand 5.7 g vertically and 9 g longitudinally.

Photo 7 - Cockpit seats

Photo 7. Cockpit seats 

1.12.8 Cockpit

The cockpit was photographed to document items such as switch and lever selections, as well as instrument readings. The speedbrake control lever was observed in the RETRACT position. The length of the lever was measured to be approximately 66.5 mm, which corresponds to the ground spoilers not being in an armed position. After the in situ physical position was documented, the lever was pulled up to the armed position and released back down into RETRACT. The flap lever was observed in the FULL position. The landing gear lever was observed in the DOWN position. The antiskid and nosewheel steering switch was ON. The EVAC ON pushbutton was found in the out, OFF position.

The aircraft is equipped with three emergency locator transmitters (ELTs); one of the ELTs is equipped with an automatic g switch, which is unidirectional along the longitudinal axis. No signals were reported to have been received from any of the transmitters. The extensive post-crash fire destroyed the structure where the three transmitters were located. No components from these beacons were identified or recovered from the wreckage.

The windshield wipers were found deployed and partway up on both the captain's and first officer's windshields. The captain's and first officer's windshield wiper selector switches were both set to the SLOW position. Rain repellent was not used.

The weather radar settings were set to the Weather and Turbulence mode, Predictive Wind Shear was on AUTO, the Ground Clutter Suppression was OFF, and the GAIN was on calibrated.

1.12.9 Tires and Brakes

There was no evidence of hydroplaning on any of the tires. All brakes had the pistons extended, and the average brake wear remaining was about 66 per cent. There was no indication of pre-impact hydraulic leakage found. Brake pedal linkages in the avionic bay (under the cockpit floor) were in good condition. The brake and steering control unit (BSCU, FIN 3GG) and both landing gear control interface units (LGCIU, FIN 5GA1 and FIN 5GA2) were recovered. All of the units were severely damaged by fire, as were the braking components in the main landing gear bay. Wheel hubcaps and tachometer assemblies were removed on main landing gear wheel positions 1, 2, 3, 4, 5, 7 and 8; the tachometer for wheel number 6 could not be removed. No visual anomalies were observed on the tachometer driving shafts.

1.13 Medical Information

For the last several years, the captain had been restricted from various flying duties for medical reasons, reportedly for a condition that made him susceptible to fatigue. On 04 September 2003, he was found fit to fly with the restriction of no flights to Africa or Madagascar for six months. On 01 June 2004, the same restriction was repeated. On 24 February 2005, he was restricted from flights to Africa and Madagascar for a period of one year.

On 11 July 2005, the captain voluntarily requested a reduced flying schedule due to an unusual level of fatigue. On 25 July 2005, upon returning from the flight before the accident flight, having consulted with his treating physician, the captain requested and was granted by Air France medical staff eight days off followed by a 50 per cent reduction in schedule for three months. He was restricted to flights to North America during this period, but flights to the west coast of North America were excluded. Further clarification with respect to the specific medical condition of the captain and any possible impact on performance was requested from the BEA medical personnel. Other than the information provided above, no medical assessment was available that would explain the ongoing fatigue symptoms experienced by the captain or their possible impact on performance.

1.14 Fire

1.14.1 Fire Initiation and Spread

Evaluation of the wreckage trail indicated that there was no fuel leakage until the aircraft crossed Convair Drive. The first debris related to the fuel tanks and the fuel distribution system was found in the field adjacent to the ravine. Traces of fuel were visible at the top of the embankment on the left-hand side of the aircraft trajectory. A piece of an internal wing box rib was also found in the same area. A wing access door panel with slight fire damage was identified among the debris deposited halfway between Convair Drive and the edge of the ravine. There was no indication of fire on top of the embankment because no scorched grass or soil was visible.

Photo 8 - Aircraft fire in progress

Photo 8. Aircraft fire in progress

The fire intensified as the aircraft came to a halt. The fire path was from the wing area toward the fuselage. By the time the fuselage was seriously threatened by fire, the aircraft had been totally evacuated. There were four principal areas of fire:

  • left-wing root main landing gear area;
  • right-wing root main landing gear area;
  • fuselage from the cockpit door to the rear pressure bulkhead; and
  • APU area.

The left wing sustained heavy fire damage at the rear spar/rib one area and the top skin had melted in the vicinity of rib five. The right wing sustained heavy fire damage to the rear spar section between ribs one and five. The top skin and the internal wing structure had melted in that location (see Photo 5). The fuselage burned from the cockpit door to the rear pressure bulkhead. The great portion of the fuselage was consumed by fire down to and including the cabin floor. Part of the right-side cabin wall was standing, though heavily damaged by fire.

1.14.2 Aircraft Rescue and Fire Fighting

In accordance with Section 301, Subpart 3 of the CARs, the GTAA provided Category 9 ARFF services at CYYZ. Due to the size of the airport, the GTAA divided the airport into two distinct airports, each with its own fire hall. The north airport includes Runway 23/05, and the parallel Runways 15L/33R and 15R/33L. The south airport includes the south parallel Runways 24R/06L and 24L/06R. The south fire hall is adjacent to Runway 24L, about 3000 feet from the threshold.

The aircraft left the runway at 2002:19. When the tower controller activated the crash alarm at 2002:45, notification went to both fire halls on the airport, the GTAA operations centre, and surrounding fire halls in the City of Mississauga, Ontario. A group of ARFF firefighters were in the alarm room of the south fire hall watching the storm and witnessed the aircraft landing. They responded before the crash alarm activation by the control tower and the first response vehicle arrived at the scene within one minute of the crash alarm sounding. This response time was well within the three-minute time standards prescribed by Section 303, Division IV of the CARs.

GTAA fire crews regularly undertake training with respect to the aircraft using CYYZ. In 2003, they had a week-long training session on an Air Canada Airbus A340. Training records are maintained and TC conducts an annual audit on firefighter training. All audit results have been positive. GTAA ARFF regularly uses electronic information sources including a website published by Airbus to study the type of aircraft using CYYZ.

The ARFF initial response team consisted of 15 members. The minimum staffing level is 11 members per shift. There were additional crews on hand at the time because firefighters were beginning to arrive for a scheduled shift change. Others were called in, arrived for their regular shift, or came in on their own initiative after hearing of the accident through the media.

The ARFF response equipment comprised one command vehicle, one rapid intervention vehicle of a 6000-litre capacity, two structural pumpers, and four major foam vehicles of a 12 000-litre capacity each. Two of those vehicles were equipped with snozzles. A snozzle is a probe located at the end of a hydraulically operated arm attached to the fire truck. It is used to penetrate the aircraft structure at designated locations and inject firefighting extinguishing agents inside. This response equipment exceeded the number of firefighting vehicles and the total quantity of water that is required under Section 303.09 of the CARs for Category 9 ARFF. The first vehicles took positions adjacent to a public road at the tail of the aircraft. Because of the terrain of the final resting place of the aircraft, the snozzle equipment could not be used.

GTAA ARFF trucks delivered an initial quantity of 39 500 litres of water to the fire, 63 per cent more than the capacity required by applicable regulations. Additional water was obtained through hydrants and subsequently through a tanker arrangement established by the City of Mississauga and the Town of Caledon, Ontario.

The primary firefighting agent used was aqueous film-forming foam. These foam concentrates are mixed with water and air and produce an aqueous film on the surface of hydrocarbon fuels to prevent evaporation. The closest fire hydrants to the accident location were about 1 km away at the GTAA bus terminal adjacent to the south fire hall. When trucks ran out of water, they shuttled back and forth to the hydrants until a tanker operation was established by Mississauga Fire and Emergency Services to supply the GTAA trucks on site.

The GTAA Emergency Operations Centre (EOC) was opened at 2018. At 2022, the GTAA mobile command post arrived at the scene and three passenger buses and a Toronto emergency services (EMS) multiple casualty bus were dispatched to the scene.

At 2141, 297 passengers were accounted for, but emergency crews were still waiting for a manifest to confirm the total number of persons on board. Currently, the GTAA ARFF command vehicle has laptop capability in order to pull up aircraft charts published on the internet.

1.14.3 Aircraft Familiarization Charts

As stated in Section 1.14.2, the GTAA firefighters had received extensive training on the Airbus A340 and had on-site access to crash charts published on the internet. GTAA ARFF personnel indicated that they routinely conduct aircraft familiarization by visiting various aircraft parked at a gate for a period of time or in a hangar for maintenance.

A binder containing aircraft familiarization charts was retrieved from one of the GTAA ARFF trucks. These charts show information particular to each aircraft model, such as locations and volumes of fuel tanks, fuel lines, emergency exits, battery locations, emergency penetration points, and other information of significance to firefighters. The charts provide value as a training aid for firefighters and other emergency response personnel and as quick reference material when response is required and other sources are not available. The retrieved binder was identified as TC's publication ERS Aircraft Crash Charts (TP 11183).

Some manufacturers such as Airbus and Boeing make these charts available via the internet. Subscriptions can be obtained for both hard-copy and electronic versions that can be incorporated into driver-enhanced vision systems14 installed in fire trucks.

In the mid-1990s, during the devolution of airport operations to local airport operators, TC ceased the production of TP 11183 and transferred its copyright to the National Fire Protection Association. At the time of the Air France occurrence, TP 11183 was no longer being produced, and the provision of such crash charts to ARFF personnel was at the discretion of individual airport operators.

The condition and contents of the manual found in the truck indicated that it was not a primary reference tool. It contained charts for aircraft that are no longer in service anywhere in the world and did not contain charts for the Airbus A340.

CAR Standards require ARFF personnel training in the following area:

323.14(1)(b)(ii) Familiarization with the types of aircraft regularly operating at the airport or aerodrome where the firefighter will be carrying out fire-fighting duties.

323.14 (2)(b)(ii)(H) Use an aircraft crash chart to identify and describe the location of normal and emergency exits, fuel tanks, passenger and crew compartments, oil tanks, hydraulic reservoirs, oxygen tanks, batteries, and break-in points for given aircraft.

Although there is no direct regulatory requirement for an airport authority to possess a set of appropriate aircraft familiarization charts, a requirement is implied in CAR Standards for training purposes.

In the late 1990s, TC initiated a series of Notice of Proposed Amendments (NPA) to update the CARs with respect to aerodromes and airports. NPAs 2000-243 and 2000-244 addressed the fact that Emergency Response Plan requirements under Section 302 of the CARs and TP 312 did not ensure that consistent planning for emergencies, commensurate with the type of aircraft and amount of traffic, is developed by the airport operators. NPA 2000-243 proposed regulatory changes in that Section 302.104(1), Aircraft Crash Charts and Grid Maps, would require that "The airport operator shall provide aircraft crash charts in accordance with the airport standards." The relevant standards, drafted in NPA 2000-244, proposed that "The operator of an airport shall provide the aircraft crash charts specific to the commercial passenger-carrying aircraft using the airport. . . ."

As of 07 October 2006, the proposed changes to Section 302.206 of the CARs had been published in Part I of the Canada Gazette as follows:

302.206 Aircraft Crash Charts and Airport Grid Maps will require the airport operator to make available at the emergency coordination centre, aircraft crash charts specific to the aircraft used by the air operators that use the airport. Copies of these charts must be supplied to the organizations responsible for fire-fighting services that are identified in the plan and to the on-scene controller.

1.15 Survival Aspects

1.15.1 General

The passenger load comprised 297 passengers: 168 adult males; 118 adult females; 8 children; and 3 infants. Adult passengers included: three wheelchair passengers and one blind passenger. Three non-revenue passengers were seated in crew seats: one in the third occupant seat of the flight deck, and two in the flight crew rest area.

The dynamic loads generated in this occurrence were within range of human tolerance. However, given the number of serious impact injuries incurred by passengers and crew located in the flight deck and forward cabin, it is apparent that significant forces were experienced in those areas of the aircraft.

1.15.2 Runway Excursion

From the time the aircraft left the runway until it came to a stop in the ravine, it bounced violently and repeatedly, and there were a minimum of three distinct impacts. On each impact, cabin occupants were propelled upward from their seats, their arms and legs flailing. It is estimated that approximately 15 to 20 seconds elapsed between the time the aircraft departed the runway hard surface and it came to a stop in the ravine. The following events occurred during the impact sequence:

  • the handset for the PA/interphone system fell out of the stowage cradle at the L1 cabin crew station;
  • a number of overhead baggage compartment doors opened, uncommanded, allowing carry-on baggage to fall into the cabin;
  • the L2 passenger door opened while the aircraft was moving, sometime after it left the end of the runway;
  • in the passenger aisle adjacent to the L2 door, the emergency exit light and a ventilation grill partially detached and hung from the ceiling;
  • some oxygen masks fell from stowage;
  • a portable serving table stowed/secured in the forward galley dislodged and fell in the cross-aisle between the L2 and the R2 exit doors;
  • the curtain rod between the passenger seating area (right passenger aisle) and the R4 exit area detached and fell on the floor;
  • one end of the curtain rod separating the passenger seating area (left passenger aisle) from the L1 exit area detached and hung down into the passenger aisle;
  • the fire started on the aircraft exterior before the aircraft came to a stop; and
  • smoke entered the cabin through the opened evacuation doors before the evacuation was complete.

1.15.3 The Evacuation

When the aircraft came to a full stop, the chief purser, in the front of the aircraft, released his seat belt and retrieved the PA handset from the floor. He was not aware of the smoke/fire from where he was standing, nor did he know that many passengers were already in the aisles making their way to the emergency exits. He made a direct PA, stating "Everything is OK - remain seated, the crew will look after you." The L2 purser then arrived and told the chief purser that there was a fire by door L3, and that an evacuation was required. The chief purser turned and faced the cabin, and saw the fire outside the aircraft through the windows on the left side of the aircraft and the passengers in the aisles. When the captain was advised of the fire and the need to evacuate, as per the flight crew's emergency procedures, he pushed the EVAC ON pushbutton to activate the evacuation alert system. The system did not respond. The cabin crew commanded the evacuation at four of the aircraft's eight emergency exits.

Fire was observed on the left wing through the open L2 door, through the viewing window in the L3 door, and through the window in the L4 door. Forty-two per cent of passengers who responded to the passenger safety questionnaire saw flames on the outside of the aircraft while it was still moving and 10 per cent saw smoke in the cabin before the aircraft came to a stop. Black smoke first entered the cabin from the left side of the aircraft, just below the windows in the area of passenger seat rows 29 and 31. When the aircraft came to a stop, smoke continued to enter the cabin, making it difficult to see during the evacuation. The L3 cabin crew member, whose station was just aft of row 31, donned a smoke hood for personal protection. There was no fire in the cabin during the evacuation.

Passengers evacuated the aircraft during heavy rainfall. Continuous heavy rainfall and thunderstorms were reported at CYYZ from about 1900 until at least 2020 when it tapered off to light rain. Most passengers appeared to be coming up the embankment along the right-hand side of the aircraft; others were scattering in both directions along the creek. One passenger, with a broken leg, was found in this area adjacent to the aircraft. The R3 steward, the supplementary cabin attendants, and a GTAA employee remained with the passenger until a team of firefighters were able to assemble and carry the passenger up the hill on a backboard. Entry was gained to the aircraft interior at the front cabin door. The flight deck and first six rows of passenger seats were checked for survivors before the firefighters were ordered to evacuate from the aircraft due to increasing danger because explosions were occurring. No one was observed to be on board. Except for the one passenger with a broken leg, no passengers were observed that required assistance by any ARFF firefighters.

1.15.4 Use of Emergency Exits

Figure 4 - Emergency exits

Figure 4. Emergency exits

At the onset of the evacuation, exits R1 and R2 were assessed by cabin attendants as unusable because the creek was immediately outside the exits. Both attendants followed the prescribed procedure for unusable exits. As the evacuation progressed, the attendants reassessed their original decision regarding the usability of exits R1 and R2, and concluded that they would have to be used to expedite the evacuation in light of the ever increasing amount of smoke in the cabin.

The forward purser knew that opened exit L2 was unusable because of the fire outside and because the slide had not deployed. However, when the aircraft came to a stop, he realized that the chief purser was not aware that the aircraft was already on fire. He rushed over to him and advised him that an evacuation was required. This action likely enabled the evacuation to begin sooner. In doing so, he did not have time to close the exit door and left the open exit unattended for an undetermined period of time. In his absence, at least 16  passengers egressed via exit L2. Two of the passengers incurred serious injuries-one when he jumped from the exit, a height of 10 to 12 feet, and the other when pushed out of the exit by other passengers. The purser subsequently returned to the L2 emergency exit and redirected passengers to the L1 exit.

When exit R3 was opened, the slide deployed but immediately deflated when it contacted debris, making it unsafe for use. As the responsible cabin attendant proceeded to close the exit door, two passengers forced their way by and jumped from the exit. It is not known what, if any, injuries they incurred. Exit R3 was subsequently closed by the cabin attendant and he redirected passengers to another exit.

Fire outside the aircraft rendered emergency exits L3 and L4 unusable. The L3 cabin attendant blocked the unusable exit and redirected passengers to the nearest available exit as per the operator's prescribed emergency procedures. The aft purser, stationed at the L4 emergency exit, did not block the unusable exit nor assign an able-bodied passenger or supplemental cabin crew member to block it; it was evident that the exit could not be used because of the fire on that side.

The R4 door was difficult to open, requiring two cabin crew members to lift the door control handle to the fully up position and push the door out. Once outside the door frame, the door moved forward easily. It appeared to cabin crew that the door assist did not engage; however, after the occurrence, the emergency operation cylinder pressure gauge was documented as being in the red zone, indicating that it functioned as designed. Approximately one door width forward of the R4 door was a permanent fold in the outer fuselage skin, indicating that the location was subjected to a substantial bending force. The deformation of the fuselage was very likely transmitted to the door frame and would explain the difficulty experienced opening exit R4.

Fire rendered two of the eight exits (L3 and L4) unusable for evacuation. Exits L2 and R3, although the slides had either not deployed or had deflated, were used by a few passengers, some of whom incurred injuries. Exits L1, R1, R2, and R4 were used. Two cabin crew members blocked access to unusable exits and redirected passengers to the nearest available emergency exit, as per the company's emergency procedures manual.

Four of the eight exits were therefore unsafe for use, or unusable: L2, L3, L4, and R3. However, L2 and R3 exits could have been used, had other options not been available. The L3 and R3 cabin crews remained at their exits, as per their emergency procedures, directing passengers to alternate available exits. Following the occurrence, the L2 cabin crew member was unable to recall very much about his actions during the evacuation. The L4 purser also left her exit unattended (unusable because of fire/never opened) while she commanded the evacuation at exit R4. The R4 cabin crew had been directed by the L4 purser to evacuate and help passengers at the foot of the slide.

Approximately two-thirds of the passengers evacuated via exit R4. The remainder evacuated via exits L1, R1, and R2, and a few evacuated at exits L2 and R3. It is estimated that the aircraft was evacuated in a little more than two minutes. A number of passengers took their carry-on baggage with them; in view of the urgency to egress rapidly because of the smoke in the cabin and the fire, this action presented a significant risk to safety.

During emergency procedures training, cabin crews are taught to use a megaphone when wearing a smoke hood so as to make themselves heard/understood. The L3 cabin crew did not have ready access to either of the megaphones on board the aircraft.

1.15.5 Exit Slides

The L1 slide partially deployed/inflated. Given the nose-down, left-wing-high attitude of the aircraft, neither the intermediate tie restraint device nor the toe tie restraint device separated from the slide. As a result, the slide came to rest folded in half against the fuselage. When passengers jumped from exit L1, some became trapped in the folded portion of the slide and were unable to extricate themselves before other passengers jumped on top of them. During the evacuation, the slide deflated completely. Post-occurrence examination of the slide revealed that it had been punctured in two areas. The tears measured 18 cm and 13 cm in length.

The L2 slide failed to deploy, rendering the exit unsafe, although a few passengers jumped out of that exit. Because exits L3 and L4 were not opened, the slides at those doors were not actuated. The R1 slide deployed automatically as designed. However, the angle of the slide was very shallow because it was almost perpendicular to the aircraft. As a result, the rate of descent was slowed considerably. At the bottom of the slide, vegetation on either side of the deployment path pushed against the slide, causing it to curl inward, forming a tube. At one point, the R1 cabin attendant had to stop the evacuation to wait for passengers already on the slide to pass through this tube. As more passengers used the slide, the bottom of the slide flattened. The operation of the R2 slide was unremarkable. The R3 slide deployed as designed; however, immediately thereafter, the slide deflated. The R3 cabin crew closed the door to prevent injuries to passengers who might try to use that exit. It was subsequently determined that the slide had torn on a piece of wreckage. The R4 slide deployed as designed. Passengers evacuated single file on dual-lane slides at positions R1, R2, and R4.

1.16 Tests and Research

1.16.1 Simulator Trials

On 25 September 2005, TSB investigators conducted simulator trials at the Airbus training facility. The Airbus simulator used for the trials is a flight crew training simulator, not an engineering simulator. Therefore, the trials were not able to achieve quantitative results, but qualitative results and a general idea of aircraft handling and pilot technique when used with the Air France standard operating procedures (SOPs). The simulator trials allowed the investigators to observe various automatic and manual modes of operation, using the actual wind profile and runway conditions present at Toronto at the time of the accident. Various profiles were flown to determine what profile the aircraft would have followed.

One of the trials in the manual mode was to fly the same profile as the accident aircraft. At approximately 300 feet agl, when the wind changed direction to a tailwind, the airspeed trend vector showed a decrease in speed. To maintain the target airspeed with autothrust disconnected, thrust was increased to about 70 per cent N1. When this additional thrust was maintained as in the accident flight, the airspeed increased. Without any pitch corrections, the simulator went above the glideslope and reproduced results similar to those of the accident profile. The tailwind and extra thrust contributed to an extended float and longer-than-normal landing. The selection of reverse thrust was delayed after touchdown and this increased the stopping distance.

The trials showed that, when landing with the autothrust on and the autopilot off, the target speed was maintained and the simulator landed within the first 2000 feet of the runway.

Using Air France procedures and notwithstanding any meteorological condition such as a microburst, the simulator trials showed that a go-around can be safely accomplished at any time up to thrust reverser deployment. In the event of a low-energy go-around in a tailwind situation, extreme caution must be used to prevent a tail strike. The simulator trials were not able to fully replicate the evolving conditions and especially the visibility associated with the extreme weather conditions present in Toronto at the time of the accident, and no conclusions may be drawn from the simulator trials with respect to pilot judgment concerning the go-around.

1.16.2 Testing of Aircraft Brakes

On 13 October 2005, the eight brake units from the main lan Transportation Safety Board of Canada - AVIATION REPORTS - 2005 - A05H0002

Transportation Safety Board of Canada
Symbol of the Government of Canada

  AVIATION REPORTS - 2005 - A05H0002

2.0 Analysis

2.1 Introduction

All aircraft systems were serviceable and working as designed throughout the approach and landing for AFR358. Therefore, a mechanical malfunction did not contribute to this accident. The analysis will concentrate mainly on the human factors and decision-making processes that were at play during the accident flight.

There have been numerous investigation reports and studies completed on runway overrun accidents, as reported in the Factual Information of this report. Although most overrun accidents, including this one, have unique elements, there are also many similarities. Throughout the industry, the information available concerning runway overrun accidents has been used to develop awareness programs and improved training procedures. Before this accident, Air France recognized the potential for overrun accidents in its operation and took measures to prevent such an occurrence. However, despite its targeted efforts, the overrun accident in Toronto essentially fits the pattern of the accident these programs and training procedures were aimed at preventing.

In hindsight, the risk presented by the rapidly deteriorating weather conditions was greater than most pilots would deem acceptable. However, when the AFR358 pilots assessed the available weather information and the traffic flow into the airport, they did not expect that such a severe deterioration in the weather was imminent. This analysis will discuss the circumstances that led to the overrun of AFR358, the adequacy of the defences that were intended to prevent this occurrence, and the initiatives that could lead to improved defences.

2.2 Aircraft

2.2.1 Emergency Exit Door L2

There was no plausible explanation found for the opening of the L2 door. The possibility that something might have hit the outer handle to trigger the opening of the door while the aircraft was crashing through fences and guard rails and sliding into the ravine through shrubbery was assessed. It was considered unlikely that this happened because the outside handle is recessed and there was no indication of mechanical damage to the handle or to the door in the handle vicinity. In addition, when the outside handle is activated, the slide deployment is automatically disarmed. Since the girt bar was found in the door sill and the arming lever in the armed position, it is reasonable to conclude that the door was not opened with the outside handle.

Consideration was also given to the possibility of the interior door panel becoming loose and unseating the interior handle from its position. In the area of the handle recess, the interior panel is securely fastened to the door frame structure by screws. It is highly unlikely that the screws and fasteners would become loose to allow the paneling to contact the door handle. Many hypotheses were studied to try to establish how this door opened. None of these hypotheses could be proven. However, the analysis positively concluded that the inside door handle had to be raised in order for the door to open. How this handle moved could not be determined.

The door started to open while the aircraft was still moving. It is possible that an asymmetric pull on the slide's release cable had developed, causing the aft release pin to jam and bend. However, if the release pin jammed, it may have prevented complete opening of the door. Since the forward pin pulled out, the forward end of the packboard was freed from the front rail, which remained attached to the door. The door would continue the predetermined trajectory, that is, move out and translate forward. The front end of the packboard would drag along the door sill while pivoting around the rear end still connected to the rear attachment rail, which travels with the door. The opening of the door would continue until the front end of the packboard butted up against the door frame or the cabin crew seat. At that point, the door would be open enough to permit passengers in single file to jump out. The packboard, because of its orientation (rear end attached to the partially open door and front end resting against the door frame) would not represent an obstacle to exiting passengers. From the deformed packboard remnant in relation to the lug, the angle of the resting position of the packboard was determined to be approximately 40º with respect to the door.

When the slide assembly started to deploy, it was hindered by the jamming of the aft release pin. In fact, the girt portion of the slide assembly, which is attached to the girt bar in the door sill, unravelled enough to protrude from the partially open door. This seems to be supported by one picture submitted by a passenger. A dark grey material (colour of the girt) is seen extending beyond the bottom of the door. It would also explain why there were no remnants of the girt found, as it would have been consumed by fire. The door, the packboard, and the girt would remain in the stuck position until the fire consumed a substantial amount of the packboard and the door support arm weakened. The attitude of the aircraft at rest (nose-down and roll to the right) would tend to favour the packboard and slide assembly falling into the cabin during the ensuing fire rather than falling to the ground.

As a result of the door having opened in this manner, the potential for smoke/fire to freely enter the cabin was introduced, presenting a significant risk to the passengers and crew. There was no attempt by the cabin crew to close this door because passengers were either exiting or being pushed through it soon after the aircraft stopped moving.

2.2.2 Aircraft Air Data Inertial Reference System - Wind Calculation

The wind speed and direction is presented to the crew's navigation displays (NDs) by the air data inertial reference system (ADIRS). Airbus documentation on this system states the following: "The wind information presented to the crew is computed from the difference between groundspeed (GS) and true airspeed (TAS) for the speed, and track (TRK) and heading (HDG) for the direction." Two aspects need to be considered for the accuracy of the wind information:

  • the yaw movements: Indeed, during a yaw movement, transitorily, the value seen on the NDs could be different than the one seen by the ADIRS unit. However, as soon as the yaw is stabilized, the value seen should be the same; and
  • the GS and TAS accuracy: Indeed, considering the accuracy of each component used for the wind speed and direction, ADIRS unit computation, the wind speed and direction displayed to the crew have to be used with care.
    GS accuracy: ± 8 knots - TAS accuracy: ± 4 knots
    Wind (> 50 knots) accuracy: ± 12 knots and ± 10º
    True track: ± 2.3º with GS=200 knots
    True heading: ± 0.4º

It should be noted that the precision on the value of the wind is not given for wind speeds below 50 knots. Furthermore, because the groundspeed accuracy was about six knots off at the time of landing, the rear wind component shown on the NDs was therefore underestimated.

2.3 Airports

2.3.1 Runway End Safety Areas

The asphalt blast pad beyond the end of Runway 24L extends for 30 m and is followed by a downward-sloping, grassy area. This area is not prepared or advertised as a stopway, nor is it required to be by Canadian regulations. In accordance with TP 312E, published in 1993, and the related ICAO standard, a strip shall extend beyond the end of the runway for a distance of at least 60 m, which the grassy area does. The ICAO standard further states that a RESA must extend from the end of the strip to a distance of at least 90 m, and that the downward slope should not exceed 5 per cent. Since TP 312E only recommends that airports meet the minimum length of 90 m for a RESA, airports are not required to provide it.

The distance from the end of the runway to the beginning of the perimeter road was 155.7 m along the centreline of the runway, which is the approximate path followed by the aircraft. Although there is no RESA published for the runway, the distance along this path was actually within the distance stipulated for a RESA in the applicable ICAO standard. Nevertheless, the ditch by Convair Drive, the fences, and the ravine beyond, with its concrete pillars supporting the approach lighting for Runway 06R, largely contributed to the damage incurred by the aircraft and the injuries to the crew and passengers.

As early as 1989, the FAA established airport design criteria that included a requirement for a RSA length of 300 m (1000 feet). By 1999, in recognition of the enhanced safety of a longer RESA, ICAO recommended that a RESA should extend at least 240 m beyond the end of the runway strip. Had a RESA been designed and published for Runway 24L in accordance with the ICAO recommended practice, an obstacle-free overrun area, free of hazardous ruts, depressions, and other surface variations, would have extended to a distance approximately 75 m beyond Convair Drive.

As stated in Section 1.10.11, alternative solutions do exist for runways that cannot meet the RESA standard or where the area beyond the RESA does not meet the recent ICAO recommended practice of a 240 m overrun area beyond the 60 m runway strip. The EMAS technology is designed to stop an aircraft where it is not possible to construct a 300 m (ICAO 60 m + 240 m) or FAA 300 m overrun. This technology has demonstrated that it provides an alternative for runways where natural obstacles, such as bodies of water or sharp drop-offs, as in the case of Runway 24L, make the construction of a standard safety area impracticable. Had Runway 24L been designed with a RESA built to ICAO recommended practice, the FAA standard, or the FAA alternate means of compliance, the damage to the aircraft and injuries to the passengers may have been reduced.

2.3.2 Adequacy of Aircraft Rescue and Fire Fighting Aircraft Familiarization Charts (TP 11183)

The aircraft crash charts binder (previously TP 11183) recovered from one of the GTAA fire trucks did not contain familiarization charts for the Airbus A340. Important information such as locations and volumes of fuel tanks, fuel lines, emergency exits, battery locations, emergency penetration points and other information provide firefighters a quick reference when response is required. While the presence of outdated hard-copy crash charts had no adverse impact on the GTAA response, it does highlight inefficiencies in the CAR requirements for the provision of crash chart information.

There is no regulatory requirement for an airport authority to possess appropriate aircraft charts. However, the CARs state that it is the responsibility of airport authorities to obtain and maintain an appropriate set of charts for training purposes. Aircraft manufacturers make these charts readily available for airport authorities. Regulations currently proposed by TC regarding airport emergency planning will establish a requirement for airport authorities to possess current charts for aircraft that regularly use the airport.

2.3.3 Adequacy of Wind Information

The two wind-recording locations at CYYZ are necessary to provide valid wind information to crews landing on widely separated runways. For purposes of providing separate wind indications, these two locations are seen as redundant and controllers are directed to provide wind information from the serviceable site if the other is not serviceable. The failure of the south field WADDS unit should have caused controllers to provide wind information to landing aircraft from the north field site. No such information was passed. As well, in the quickly changing conditions at the time, wind information from a measuring site far removed from the landing runway would have had no value.

Windsock-based information provided to the tower by the two landing aircraft immediately ahead of AFR358 provided data about the wind on the runway, and this information was transmitted to the crew of AFR358. The wind information provided by ATC to aircraft provides data about the wind at the recording point, not as it is affecting the aircraft at its position.

Nevertheless, wind information is critical to aircrew during the landing, particularly in adverse weather conditions when much of their attention is concentrated on maintaining visual contact with the runway. In these situations, controllers often continue to provide wind information beyond that required in the operations manual. Since the ability of controllers to provide immediate and relevant wind information could prove critical to the safe landing of an aircraft, the provision of this service should not hinge on the failure of a single electronic component.

2.4 Weather

2.4.1 Adequacy of Meteorological Data

The forecasters at the CMAC-E of the MSC followed the relevant standards to produce the TAFs (regular and amended issues) and to issue convective SIGMETs. The forecasters introduced thunderstorms in TAFs as early as 14 hours before the accident. These thunderstorms were kept in all TAFs as a 30 per cent probability up to two hours before the accident. The last TAF issued 1.5 hours before the accident indicated a TEMPO (temporary change) of thunderstorms with visibilities of 2 sm until four minutes before AFR358 landed, thereafter a PROB 30 of the same conditions. Also, a SIGMET indicating a line of thunderstorms was issued 45 minutes before the accident. Based on the information available to the forecasters at issue time, the forecasts were of good quality and complied with accepted practices. All the forecasts met the standards and were issued on time.

2.4.2 Weather Information Provided by Air Traffic Control

The Air Traffic Control Manual of Operations requires controllers to provide landing information to aircraft. In Toronto, the latest weather is recorded on the ATIS for use by inbound crews. ATIS message Uniform was the latest available weather information, and the AFR358 crew members indicated that they had received Uniform when they contacted Toronto arrival. Apart from the information provided through ATIS, ATC endeavours to provide other information that would be of assistance to aircrew. Information concerning poor braking action was passed on several occasions. The radar used in the Toronto tower by ATC is not specialized weather radar and does not provide highly detailed weather information. Therefore, the crew of AFR358 had a better view of radar-derived weather information from their aircraft's weather radar than the controllers did from their own display.

There is no indication that more sophisticated weather radar information, had it been available to ATC and communicated to the crew of AFR358, would have altered their decision to continue to land. However, without some indication of the speed and direction of intense, rapidly moving weather phenomena, controllers are limited in their ability to provide information that might be of assistance to aircrew. Controllers attempt to use the runway most nearly aligned into the wind. However, because of weather and ILS outages due to lightning strikes, the landing runway had been changed several times.

At 1856, the ILS localizer for Runway 24R became unserviceable, forcing the use of Runway 23 for some time. Some arriving aircraft, however, were refusing the approach to Runway 23 because of the nearness of the storms north of the approach path. At 1913, the ILS glideslope for Runway 23 became unserviceable and, with the unserviceability of the glideslope for Runway 24R, the only remaining runway aligned into wind was Runway 24L. Under normal circumstances, the preferred approach and landing runway is announced in the ATIS broadcast. Equipment outages for extended periods are advertised by NOTAMs. There was no indication from the crew that use of Runway 24L was unacceptable. The final decision on the acceptability of a particular runway rests with the aircraft captain.

Given the limitations of the information available on board, crews may require assistance in projecting the weather situation into the future and may look to ATC for additional information. This was certainly the case in the accident flight because the crew made multiple requests to ATC during the initial approach phase for information with respect to the developing weather conditions. Crews may believe that ATC will be able to provide the most up-to-date information as they have local climatological knowledge, are located at the airport (in the case of tower controllers), and may be aware of what other aircraft are experiencing. However, ATC's ability to provide up-to-date weather information during rapidly changing conditions observed with thunderstorm activity is quite limited. Further, some crews have an inaccurate belief that ATC will close airports based on weather conditions.

2.5 Flight Operations

2.5.1 Crew Rest

There is little information to suggest that the occurrence crew members were fatigued or that their performance was degraded by the effects of fatigue. The accident occurred at approximately 1600 local time, which is 2200 at the crew's point of departure, the time zone to which the crew were adapted. This does not correspond to a circadian low. Although the crew members were nearing the end of a long flight, they were only 10.5 hours into their duty day. While the crew members were naturally feeling tired from the flight, particularly given that this is one of the longer flights Air France conducts without an augmented crew, the duty day was not so long that the performance of a normal, healthy individual should be adversely affected by fatigue.

Both the captain and first officer had been off for sufficient time before the flight to allow them to obtain sufficient restorative sleep, and both were well rested before beginning the flight. Although the captain had declared that he had recently been experiencing an unusual level of fatigue, the aeromedical centre (AMC) had determined that his condition did not affect his fitness to fly. Based on AMC's determination, Air France medical staff put in place a reduced flight schedule for the captain. BEA's medical physician was requested to provide an assessment of the possible impact of the captain's medical situation on his performance. No medical assessment was available to the TSB.

2.5.2 The Accident Flight

There was nothing unusual in the pre-flight activities of the flight crew. The addition of three tonnes of holding fuel for the accident flight was considered standard practice for the weather conditions that were forecast. There was no perceived pressure within the company to preclude carrying additional fuel, and the captain was not hesitant to do so.

For Air France flights, the primary alternate is selected by the company's flight planning software based solely on proximity. However, the flight crew must ultimately determine a suitable alternate after assessing the weather and any other operational factors. The ease with which flight plans can be modified ensures that flight crews are not under any undue pressure to automatically accept the closest airport.

While en route, although the pilots were not receiving updated TAF information for their destination or alternates, the forecast weather did not change appreciably. Therefore, it is unlikely that they would have altered their decision making, even if they had received the updated TAF information.

As they came closer to Toronto, the flight crew members were concerned about the thundershower activity at destination. Initially, their concern was focused more on the approach delays caused by the thundershowers than on the potential for the thundershower activity to adversely affect the flight during the approach. They were not alone in this thinking, as several other aircraft were making the same assessments and judgments about the delays and weather conditions. Some pilots chose to divert, while others decided to continue. To preserve the option of a diversion, the AFR358 pilots were closely monitoring their fuel to ensure that they had enough to divert to CYOW.

In preparation for landing, the pilots gave extra attention to monitoring the weather and calculating diversion fuel requirements. Neither of these activities was unusual, and there is no indication that these activities kept the pilots from effectively completing other piloting activities, with one exception: the non-formal completion of the pre-landing checklist. All checklist items were completed, but not through the normal challenge and response process. There is no indication that they became so focused on weather and fuel considerations that they lost their ability to assess the big picture.

There is no indication that the pilots determined the landing distance required for a landing at CYYZ for any of the possible runway conditions that they could have faced. The Air France procedures did not require a determination of landing distance required.

As the approach continued, the pilots knew that the weather near the runway would be affected by the nearby CB clouds. However, they assessed that their margin of safety was not unduly compromised. They briefed the windshear procedure and were prepared to initiate an immediate go-around in the event that they received a windshear alert. Their decision to continue with the approach was consistent with normal industry practice, in that they could continue with the intent to land while maintaining the option to break off the approach if they assessed that the conditions were becoming unsafe. Until the decision height of 200 feet, the aircraft was stabilized, although an airspeed increase and a deviation above the glideslope were beginning to occur around this height. From then on, the deviations were below the threshold at which the PNF was required to make a call regarding the deviations.

The point at which the situation changed from normal and manageable to abnormal and critical was near the runway threshold when the aircraft entered the perimeter of the cell activity. At this time, a number of circumstances combined, leading directly to the accident.

The PF was monitoring the airspeed trend vector and responded to an indication of decreasing airspeed by adding power; however, he kept it there too long. Had the autothrust been engaged, the engine power would have been adjusted to maintain the proper airspeed, and it would have been more likely that the aircraft would have been landed closer to the target touchdown point. At that very time, both pilots became preoccupied with the reduced forward visibility, and airspeed scanning rate decreased. Without the airspeed control provided through the autothrust, the increase in energy from the extra thrust increased the airspeed and groundspeed.

As they crossed the runway threshold, with the heavy rain, low visibility, lightning, and shifting winds, the flight crew members became overwhelmed by the severe weather conditions and became task saturated, making a normal landing difficult. The pilots, who were by this time both focusing primarily outside the aircraft, were not aware that a wind shift was also occurring. While they were in the flare and the initial float, the pilots did not appreciate how much of the runway was being used up. The tailwind component contributed to the aircraft going above the glideslope and to the overall landing distance required.

The heavy rain obscured vision through the windshield and severely reduced the forward visibility. Both pilots were relying heavily on the side windows to try to determine the position of the aircraft, laterally and vertically. This caused the additional problem in that both of them were now fully concentrating on trying to determine the position of the aircraft. This might partially account for the slow reaction time of the PF to reduce power to idle. In such circumstances, it can be difficult to keep a trajectory toward, or even distinguish, the normal aiming point on the runway.

The FDR readout shows that, at touchdown, the aircraft was not aligned with the runway and it was not on the centreline. During this part of the landing, the PF was fully occupied in dealing with aligning the aircraft and keeping it on the runway in the crosswind conditions.

The delay in deploying the thrust reversers can be attributed to pilot task overload during the touchdown phase. During the confusion, the standard "Spoilers" and "Reverse verts" calls were not made by the PNF. Had the required calls been made, the PF may have used the reversers earlier. The PF was completely engaged in keeping control of the aircraft to avoid drifting off the edge of the runway. In view of the reduced visibility, it would have been difficult for him to rapidly correct for deviations from the centreline. Even if the thrust reversers had been deployed, it is unlikely that the PF would have selected full reverse in the early stages of the rollout because Air France procedures, in accordance with the FCOM, call for reverse thrust to be reduced if the aircraft is not aligned and/or is drifting off the centreline in crosswind conditions.

The delay in the selection of the thrust reversers and the subsequent delay in the application of full reverse thrust added to the landing distance needed. The condition of the runway reduced the braking action available to bring the aircraft to a stop on the remaining runway. Due to the rapidly shifting winds, the crosswind limitation for a contaminated runway was exceeded; this factor increased the difficulty faced by the crew in maintaining the runway centreline. At the point where the aircraft touched down, for contaminated runway conditions, there was not enough runway remaining to bring the aircraft to a stop. According to the second chart in Section 1.6.4, with the 10-knot tailwind prevailing at the time of landing, the aircraft would not have stopped in the runway remaining, even if the runway had been wet instead of contaminated.

Air France Airbus A340 crews have the option of conducting a go-around during an approach when it becomes evident that it is unsafe to land. In theory, the decision to go around can be made as late as when the aircraft is on the ground, as long as reversers are not yet selected. Under normal conditions, this is not a problem.

When the aircraft was near the threshold, there were ominous thunderstorms with lightning strikes on the missed approach path. At this point, the crew members became committed to landing and believed that their option to go around no longer existed.

2.5.3 Autopilot and Autothrust Use

Air France provides no specific direction to its pilots as to when to disconnect the autopilot while conducting a Category I approach. Similarly, Airbus makes no recommendation on this issue. The autopilot is certified for use down to 160 feet agl for Category I approaches, but the crew disengaged the autopilot at about 350 feet. It would be beneficial to study the advantages of keeping the autopilot engaged down to the lowest altitude authorized during approaches when weather is on the limits for the approach and/or in poor visibility conditions. This would reduce the pilots' workload and allow them to concentrate on other tasks.

Air France's practice as to when to disconnect the autothrust differs from the Airbus recommendation and from the practice of the other operators who were surveyed. There appears to be much more consensus from Airbus pilots about following the Airbus recommendation to leave the autothrust engaged throughout the approach because its use reduces the workload of the PF. As well, the autothrust can generally react faster and more accurately than a pilot to control airspeed. The results of the simulator testing support the use of autothrust throughout the approach.

The glideslope and airspeed deviations on short final, following a normal, stabilized approach, can be attributed directly to the severe and unexpected weather conditions. However, analysis of this accident has shown that keeping the autothrust engaged would have significantly reduced the crew's work level.

2.5.4 Approaches in Convective Weather

Thunderstorms can present a significant risk to the safe operation of an aircraft, and the ability of flight crews to assess the risks associated with these hazards in a timely manner is critical to flight safety. Despite the risks associated with these hazards, both research and previous accident investigations have shown that the penetration of convective weather in terminal areas during approach to landing is an industry-wide practice. The same research shows that aircraft most often deviate around convective weather outside the terminal area where there are more options available. Therefore, pilots are aware of the hazards presented by convective weather but regularly determine that the risk associated with flight into convective weather is acceptable to facilitate landing at destination.

The nature of convective weather and the quality of information available to crews to assist in assessing the risks associated with convective weather make it difficult to obtain a clear picture of the actual level of risk associated with a particular storm. In fact, convective weather has all the factors associated with an increased probability of decision errors in previous studies of pilot decision making. Convective weather is dynamic, and many of the most significant hazards described above occur rapidly and with little warning (for example, rapid changes in wind speed or direction, in visibility, in runway conditions).

Further, much of the information available to a flight crew is ambiguous in that it only provides indirect information with respect to the individual hazard. While heavy precipitation returns are associated with all the hazards of convective weather, one can often see heavy precipitation returns without experiencing any hazards. Therefore, multiple sources of information must be combined to make a judgment about the actual risk at the time and to project what the weather will be like in the future. This judgment can easily result in an underestimation of the risks. The likelihood of underestimating the risk associated with convective weather increases with each successive encounter with convective weather that does not produce adverse consequences. Furthermore, such decisions are made in the face of competing goals; making a decision to divert based on ambiguous information in a highly changeable situation may be difficult for a crew to justify.

The crew members were well aware of the presence of thunderstorms in the Toronto area. They had been forecast to occur, and the crew had elected to carry extra fuel to increase their available options on arrival at Toronto. During the descent and approach, the crew members were actively seeking additional information about the weather and examining the viability of various alternates. They had been receiving regular updates on the conditions in Toronto, having made multiple requests for the METAR and having received the active SIGMET through the ATIS broadcast. During the approach, they were receiving information that clearly indicated that there was significant weather over the airport: the weather radar was showing red areas close to the runway, there were pilot reports of poor braking action, the crew could see lightning in the vicinity of the airport, and several pilot reports indicated that the winds were increasing and changing direction. In spite of all these cues, the crew members determined that there was no clear indication that the approach should be discontinued, and they became committed to land. They had briefed for a diversion and were ready to go around.

It was not until very short final that there were clear indications available to the crew that the flight had progressed to a point where landing was not advisable - the aircraft had departed the glideslope and entered an area of intense precipitation and reduced visibility. The crew had two courses of action with potentially undesirable outcomes: proceed with an approach that was becoming increasingly difficult, or conduct a missed approach into potentially dangerous conditions. At that moment, although Air France procedures called for a go-around anytime the ideal trajectory is not maintained up to thrust reverser deployment, the captain, doubting that a go-around could be conducted safely, committed to continue with the landing.

Air France had identified the potential for a weather-related landing accident and had made addressing this risk a focus of its flight safety program before the accident. The primary action taken in this regard by Air France was to practice and encourage a go-around anytime up to thrust reverser deployment. While this goes some way toward addressing the risk of this type of accident, it does not completely address the problem faced by a crew approaching into convective weather; the hazards particular to convective weather, including windshear and microburst, may increase the risks associated with a low-energy go-around. Further, these hazards may present themselves with little warning. While these phenomena are possible with any thunderstorm, they are not present with all thunderstorms. As was the case in this occurrence, conditions can change very quickly, with one aircraft encountering manageable conditions on approach and the next experiencing quite different conditions.

For the cruise portion of the flight, Air France, like other airlines, has clear guidelines as to how far the aircraft should be operated from convective weather. Although crews are still required to exercise some judgment in these situations, they have some clearly established best practices to follow. However, for the approach and landing portions of the flight, no such guidelines exist at Air France and many other airlines. Following Air France's 1999 accident at Pointe-à-Pitre, the company reviewed the feasibility of incorporating such guidelines into its MANEX. Although the company's internal accident report clearly identified the difficulty involved in being able to assess the risks associated with convective weather, the review concluded that such guidelines were contrary to the goal of enabling crews to make decisions based upon each specific situation.

However, some companies do provide such guidelines and, in some cases, directives related to approaches around thunderstorms. Previous accident investigations have recognized their value to assist crews in making decisions in situations where the choices before them are less than obvious. These guidelines and directives have a direct effect in minimizing the impact of operational pressures, stress, and fatigue on such decisions. In the absence of clear guidelines with respect to the conduct of approaches into convective weather, there is a greater likelihood that crews will continue with approaches into such conditions.

2.5.5 Weather Information for Predicting Convective Weather

The ability of flight crews to develop an accurate assessment of the current and future state of the weather is critical to effective decision making. Due to increasing time pressure nearing top of descent and during approach and landing, information should be presented in a format that minimizes the amount of synthesis and interpretation required of the user. Given the aim of developing situational awareness, the weather information presented should also allow the user to project into the future and anticipate the future state of the weather.

This occurrence clearly demonstrates how the changeable, unpredictable nature of convective weather makes it difficult to achieve these aims. In this occurrence, although the crew made a concerted effort to gather information with respect to the current weather conditions and although they were offered additional information with respect to wind and runway condition by the tower before landing, they were very surprised by the intensity of the weather encountered as they approached the threshold.

The perception of the crew during the approach was in contrast to the perception of many who were in a position to view the intensity of the storm from the ground in the minutes before the accident. The difference in perception of the storm was not limited to the accident flight crew in that they were one in a line of aircraft on approach for landing. Aircraft landed on Runway 24L approximately 9, 6, 4, and 2 minutes before the landing of AFR358 and there was at least one additional aircraft on approach behind the occurrence flight. It is noteworthy that all these crews had also elected to conduct their approaches in conditions similar to those encountered by AFR358.

Therefore, when dealing with convective weather, the information available to a flight crew on approach does not optimally assist the crew in developing a clear idea of the weather that may be encountered later in the approach. Given the localized, changeable nature of thunderstorms, the weather experienced by those close to or under the storm may not be anticipated by those approaching the storm.

2.5.6 Landing on Contaminated Runways

For the Airbus A340-300, the maximum crosswind limit is 10 or 15 knots if the runway is contaminated. The flight crew was aware that heavy rain was occurring over the landing runway. During the approach, they observed the runway to be shiny, like the surface of a lake. These indications suggest that there would likely be more than 3 mm of water on the runway; however, the flight crew members either did not take this into account or realize this when they continued with the approach and landing, although they knew that the crosswind exceeded 10 knots.

The flight crew members were aware of the landing distance available when using Runway 24L, but there is no indication that they were aware that the MANEX full-flap landing distance required when using a contaminated runway with a tailwind exceeded the runway length of Runway 24L.

In addition, the flight crew had reports from the two previous landing aircraft that the braking action was poor. Air France procedures that apply to the Airbus A340 for the above statement stipulate that, if no measured coefficient of friction is available, the runway is to be considered as contaminated if the braking action is reported as poor.

During the investigation, a number of pilots, from Air France and other operators, were consulted about operations on water-covered runways. There is widespread consensus that the lack of runway condition information in heavy precipitation is a safety issue; however, there is no consensus as to how reports of braking action from preceding aircraft are interpreted by following aircraft. This is especially the case if the preceding aircraft is relatively small compared to the following aircraft.

Flight crews are expected to adhere to the limitations for their aircraft, including the crosswind limits. However, for operations on wet runways, there is no definitive way for flight crews to determine runway conditions such as water depth before landing. Pilot reports about braking are not consistently given sufficient consideration in decision making.

2.5.7 Crew Resource Management / Threat and Error Management

The principal threat to which AFR358 was exposed was the forecast convective weather at the planned time of arrival at destination and at the alternate. This threat was mitigated by the crew by the addition of three tonnes of additional fuel, which would allow the aircraft to hold for approximately 23 additional minutes. Given the normally transitory nature of thunderstorms, the crew felt that this was an adequate measure.

At 1950, the crew members observed red on their radar display near their intended approach flight path and decided to continue the approach with caution. This may be seen as an operational decision error through the framework provided by the TEM model; the decision error increased the risk to which the flight was exposed. However, the continuation of approaches into convective weather is widespread throughout the industry and the crew members took action to mitigate the threat by reviewing the windshear recovery procedure and discussing their flight path in the event a missed approach was required. They discussed where the cells were located, and planned to turn left and go in between the two cells if they had to overshoot. The above is an indication that, at 1950, the crew still believed that an aborted approach could be safely conducted at anytime during the approach.

During the late stages of the approach, the general threat of convective weather, which the crew had been anticipating and taking action to mitigate throughout the flight, began to manifest itself as more specific hazards. At the time, although the combination of these hazards was ominous, it was not sufficiently compelling to the crew to warrant breaking off the approach. Specifically, the threats were a significant crosswind, reports of poor braking action, and reduced visibility due to heavy rain and lightning. The crew took action to address two of these items individually: the autobrakes were set to medium to account for the runway surface condition; the captain discussed the need for a positive touchdown on the wet runway; and the PNF was monitoring the winds and advising the PF.

The crew coordination throughout the flight and the initial part of the approach was reasonably effective. Significant threat management behaviour was observed on the part of the crew, and errors observed were trapped or inconsequential. The overall risk to which the flight was exposed increased during the late stages, when the crew elected to continue their approach in proximity to convective weather. This led the aircraft to be exposed to the threats of reduced visibility and a crosswind-tailwind component. Cues received earlier in the approach were not sufficiently compelling to the crew to cause them to abandon the approach. The inability of the crew to anticipate and then respond to the threats that occurred late in the approach led to several proficiency errors and ultimately to the aircraft's departure from the glide path. The crew's underestimation of the hazards associated with the thunderstorm at the airport cannot be attributed to inadequate interaction and communication.

2.5.8 Use of Rain Repellent

At Air France, the rain repellent capability of the aircraft had been put back into operational service in 2002, but the occurrence crew was unaware that this capability had been reinstated. A survey among other pilots flying aircraft that have this system revealed that many of them either do not use or do not know under what conditions it would be advantageous to use it. The industry would benefit from more definitive information about the efficiency of rain repellent systems and more guidance on their use, to include the timing of the application.

2.5.9 Captain-Only Missed Approach Call

At Air France, the decision on whether to initiate a go-around, a missed approach, or a balked landing (hereinafter called a missed approach) is made by the captain, regardless of who is flying the aircraft. However, the first officer has a responsibility to suggest a missed approach if he or she deems it necessary. Having more than one pilot responsible for making the call about a missed approach can increase the likelihood that an unsafe condition will be recognized early and decrease the time it might otherwise take to initiate the missed approach.

2.5.10 Decision-Making Training for Difficult Approaches

This accident has a large number of factors in common with many similar accidents. These accidents happened during day and night approaches and involved well-trained crews. The crews had landed their aircraft in difficult conditions before and prided themselves in their ability and professionalism. Thorough accident investigations into accidents similar to this one, along with very well thought-out conclusions, findings, and recommendations, have not made much of a dent in the number of such accidents, which continue to happen around the world. In fact, 20 such accidents to large commercial operators have occurred in the last five years. Furthermore, a number of recent incidents, with similar factors involved, clearly had the potential for catastrophic results. If this trend continues, the resultant risk of loss of life and damage to property and the environment will increase considerably. This is worrisome because it is a clear indication that, in spite of the efforts of all concerned, and although we are learning from these accidents or the experiences of others, we seem unable to develop adequate tools to mitigate this specific risk.

Some or all of the following conditions were present in all of these accidents:

  • the crews were on approach behind or in front of other aircraft that were landing or intending to land;
  • a CB cloud or monsoon storm was approaching or was over the landing area at the time of landing;
  • heavy rainfall was occurring;
  • the runway was contaminated by water;
  • poor braking action was either reported by previous aircraft or was experienced by the crew of the accident aircraft;
  • there was a strong crosswind, tailwind, or combination of both;
  • the aircraft deviated from the target speed and glideslope on short final;
  • there was a windshear, perhaps associated with downdrafts;
  • a missed approach or balked landing was not considered or attempted;
  • the aircraft landed long;
  • the after-touchdown actions by the crews were non-standard; and
  • most often present, the accident crew members were subjected to sudden reduced visibility, which they had not anticipated properly and which they were not prepared to deal with.

In spite of all the warning signs evidenced by the above conditions, the crews of the accident aircraft were confident in their ability to perform a safe landing. The decision to continue the landing after the runway environment was lost was most often the final condition leading to the accident.

Crews need to be more acutely aware that an approach near convective weather is a hazardous situation to begin with. They must acquire a better understanding of all the conditions that they may expect to be faced with on final approach. They must be ready to conduct a missed approach at anytime one of these conditions escapes their control or understanding. They must not get themselves into a situation where the missed approach option is no longer available.

In this accident, a number of the developing conditions discussed above escaped the understanding, and therefore control, of the crew early enough on the approach. These conditions warranted a decision to go to the alternate before it was felt by the captain that an overshoot was no longer an option.

When a crew arrives at the DH on a precision approach, there are two options to consider: continue and land or go around. The go-around decision is the easiest because every pilot trains for such a possibility or eventuality. The aim of recurrent and annual simulator training rides is to confirm that crews will indeed conduct a missed approach when the visibility criteria are not met at the DH.

On the other hand, a decision to continue and land when the visible cues are very faint at best at DH is a stressful one for a pilot. Should visual cues then diminish or disappear after the decision to land has been made, the first feeling or impression on the part of pilots is one of incomprehension, followed by a period of inaction, where they wonder what just happened, and where they wish that things will get back to normal soon. This lack of reaction while waiting for the runway environment to re-appear is because the brain becomes task saturated at that very moment, unless the pilot has been trained to react instinctively and immediately to the threat. Naturally, the correct action must be an immediate go-around. The Board believes that, if more training could be done in this respect, the rate of these types of accidents would decrease.

2.6 Survivability

2.6.1 General

The evacuation was successful due to the training and actions of the whole cabin crew. With few exceptions, the performance of the cabin crew was exemplary and professional, and was a significant factor in the successful evacuation of the accident. There was effective communication between the flight crew and the cabin crew. Because the cabin crew were advised of the possibility of a missed approach, they were in a state of heightened awareness during the landing phase and were, therefore, prepared to respond immediately in the event of an emergency.

The availability of three supplemental cabin crew members on AFR358 undoubtedly contributed to the success of the evacuation, as evidenced by the roles they played during the evacuation. Two were in command of passenger evacuations at emergency exits and the third played a pivotal role in opening an emergency exit and subsequently assisted passengers at the foot of the R4 slide.

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  AVIATION REPORTS - 2005 - A05H0002

The Transportation Safety Board of Canada (TSB) is investigating this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Because the investigation is ongoing, the information provided is subject to change as additional facts become available.

The purpose of this communication is to update interested organizations and persons on the factual information gathered to date, to provide information regarding safety-related activities, and to provide information about further investigation activities. The analysis of the available factual information is still under way; consequently, it would be inappropriate to speculate as to the findings of the Board on this occurrence.

Aviation Investigation Update
Overrun
Airbus 340-313
Air France Flight 358
Toronto/Lester B. Pearson International Airport, Ontario
02 August 2005

Investigation Update Number A05H0002

Ce point sur l'enquête est également disponible en français.

Synopsis

On 02 August 2005, the crew of Air France Flight 358 (AF358), an Airbus 340-313, French registration F-GLZQ, serial number 289, conducted an approach to Runway 24L at the Toronto/Lester B. Pearson International Airport (LBPIA), Ontario, Canada. At 1602 eastern daylight time1, the aircraft landed long, overran the end of the runway and came to rest in a ravine just outside the airport perimeter. There were no reported dangerous goods on board the aircraft. An ensuing fire destroyed the aircraft. Two crew members and nine passengers received serious injuries.

Investigation Organization

The Transportation Safety Board of Canada (TSB) was notified of the accident by air traffic control (ATC) services provided by NAV CANADA at LBPIA within minutes. The TSB Ontario regional office responded immediately by sending investigators to the site. The TSB deployed a major occurrence investigation team to the site within 12 hours of the accident.

The investigation management team is composed of one Investigator in Charge (IIC), one deputy IIC, and two investigator leads - operational and technical. The operational lead is in charge of the following groups: operations, aircraft performance, witness coordination, cabin safety, air traffic services, weather, and airport/emergency response services. The technical lead is in charge of the following groups: flight recorders, powerplants, structure, systems, photo/video, site manager, site safety, site survey, and maintenance/technical records.

The investigation team for the field phase of the investigation comprised 35 TSB investigators, supported by accredited representatives from the Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile (BEA) of France and the National Transportation Safety Board (NTSB) of the United States, and 43 observers from the following entities: Transport Canada, the Federal Aviation Administration (FAA) of the United States, NAV CANADA, Air France, Airbus, General Electric, the Aircraft Accident Investigation Branch (AAIB) of the United Kingdom, Goodrich Corporation, the Peel Regional Police, and the Greater Toronto Airport Authority (GTAA). The field phase of this investigation was completed on August 16, when control of the site and Runway 24L were returned to the GTAA.

The post-field phase of this investigation is being conducted from the TSB Engineering Laboratory in Ottawa, Ontario, Canada. Selected team members travelled to France and visited the BEA, Air France, the Direction Générale de l'Aviation Civile (DGAC), Aéroports de Paris, and the Airbus manufacturer in Toulouse to gather further information related to the operations of the airline and the regulatory activities of the DGAC. The visit also provided an opportunity for the IIC to give a press conference to aeronautical specialists with the French press. Simulator flights were performed at the Airbus facility to assist the investigators in further understanding all the factors involved in this accident. Follow-up interviews were conducted with flight and cabin crews, as well as with several management personnel from Air France.

Factual Information

AF358 departed from Charles de Gaulle Airport, France, at 0753 with 12 crew members and 297 passengers on board. The flight to Toronto was uneventful, and, at 1556, the flight was cleared for an approach to Runway 24L. The co-pilot was assigned the pilot flying (PF) duties for the approach and landing. During the descent to the airport, the crew requested heading deviations from ATC on two occasions to avoid thunderstorm cells; these deviations were authorized.

Weather Data

On 02 August 2005, the major weather influence in the Toronto area was a high pressure system extending from northern Hudson Bay, Canada, to eastern Kentucky, United States, and a low pressure system northeast of Québec, Quebec, Canada, associated with a weak surface trough extending along the St. Lawrence River and over southern Ontario.

The forecast issued by Environment Canada just before 0800 indicated a 30 per cent probability of thundershowers with a visibility of 2 statute miles (sm) and a ceiling at 2000 feet above ground level (agl) for the period between 1300 and 1800. After 1200, when thunderstorm activity was first observed in the vicinity of the airport, the forecast was amended to reflect the greater probability of thunderstorms for the next hour. The forecast was subsequently amended in a similar manner each hour as thunderstorms persisted in the observations.

Shortly after 1500, a significant meteorological forecast (SIGMET) was issued indicating that an organized line of thunderstorms had developed within 20 nautical miles (nm) either side of a quasi-stationary line from 20 nm west of Buffalo, New York, United States, to 50 nm southwest of Muskoka, Ontario, with maximum tops of 44 000 feet. The SIGMET was valid until 1915.

At 1500, one hour before the landing of AF358, there was a thunderstorm and heavy rain, with reduced visibility to 4 sm and a broken ceiling of 5000 feet at the airport. At 1600, the conditions were essentially the same with remarks of cloud-to-cloud lightning and lower visibility in the southwest-to-northwest quadrant. Surface winds at that time were 290 degrees true at 11 knots.

During the flight, the crew members requested and received several aircraft communications addressing and reporting system (ACARS) messages with meteorological updates as well as some updates from ATC. They changed their initial planned alternate airport, Niagara Falls, New York, United States, to Ottawa. At 1554, a lightning strike damaged the wind direction and speed indicating system in LBPIA's control tower for Runway 24L; this information was passed to the crew who had actual wind direction and speed relative to the aircraft position continually available on its flight management system (FMS). Storm activity was visible on the aircraft's weather radar - one to the north of Runway 24L and another one to the southwest. The crews of two previous aircraft that landed just before AF358 reported that braking action was poor, and one crew estimated that the surface wind near the runway was from 290 degrees magnetic at 15 knots, with gusts to 20 knots. This information was passed to AF358 by the tower controller.

At about the time that AF358 landed, a sharp boundary of rain associated with the thunderstorm moved approximately north to south over Runway 24L, accompanied by wind gusts and a change in surface wind strength and direction. Severe lightning and lightning strikes were also reported during this period. At 1604, the conditions observed at the weather site to the south of Runway 24L were winds 340 degrees true at 24 knots with gusts to 33 knots, severe thunderstorm activity over the airfield with a visibility of 1 sm in heavy rain, and a reported ceiling of 4500 feet agl.

Digital Flight Data Recorder Information

During the final approach phase, the aircraft's FMS showed the wind coming from 300 degrees true at between 15 and 20 knots, with an approximate 8-knot headwind component. The crew changed the aircraft's automatic brake setting from the "low" to the "medium" position in view of the expected reduced runway friction conditions for the landing. The aircraft was aligned with the localizer and glide path. The approach speed was 140 knots, appropriate for the computed aircraft weight of 185 tonnes for the landing. The autopilot and auto-thrust systems were engaged for the approach. Both were disconnected at about 350 feet above ground, from which point the crew continued with the approach visually and landed in accordance with the airline's standard operating procedures (SOPs). The aircraft then went slightly above the glide path and arrived over the runway threshold at an estimated height of 100 feet; the normal height at that point is 50 feet. At that time, the indicated airspeed increased from 139 to 154 knots. During the flare, the aircraft entered a heavy shower area, and the crew's forward visibility was significantly reduced as they entered the downpour. The digital flight data recorder (DFDR) recorded wind veered to 330 degrees true, causing a tailwind component of approximately 5 knots. The runway became contaminated with at least ¼ inch of standing water.

The aircraft touched down approximately 4000 feet down the 9000-foot runway. The spoilers deployed automatically after touchdown and the DFDR recorded that the crew applied maximum pressure to the aircraft's brake pedals. The pressure remained constant until the aircraft departed the end of the runway surface.

The DFDR data show that the thrust resolver angle on the throttles' angular position began to change at 12.8 seconds after touchdown, and that the thrust reversers were fully deployed by 14 seconds. Maximum reverse thrust was observed on the engines 17 seconds after touchdown. The aircraft departed the end of the runway at a ground speed of 79 knots. It came to rest 1090 feet beyond the departure end of the runway. The DFDR data show that the aircraft landed with 7500 kg of fuel; 4500 kg of trip fuel was required to fly to Ottawa.

Aircraft Landing Performance Information

The length of Runway 24L is 9000 feet (2743 metres). Based on the Air France A340-313 Quick Reference Handbook (QRH), page 34G, "Landing Distance Without Autobrake," the following minimum distances would be used to bring the aircraft to a complete stop. It should be noted that, for a dry runway condition, the QRH shows a correction factor of "0" for landing distances with or without reverse thrust; therefore, for a given wind condition, these numbers remain the same.

ACTUAL LANDING DISTANCE
(from 50 feet above ground to complete stop)
Runway Conditions Dry Wet 6.3 mm (1/4 inch)of water
  metres feet metres feet metres feet
No wind 1155 3788 1502 4927 1987 6519
5-knot tailwind 1264 4148 1682 5518 2265 7432
No wind, reversers operative 1155 3788 1397 4582 1768 5802
5-knot tailwind, reversers operative 1264 4148 1564 5132 2016 6614

Evacuation and Emergency Response

After the aircraft stopped, flight attendants observed a fire outside the aircraft and gave the evacuation order. The airport's emergency response services (ERS) personnel and vehicles arrived on site within a couple of minutes of the aircraft coming to rest. Their primary task consisted of assisting with the evacuation of the passengers and crew to a safe area and the control of the rapidly intensifying fuel-fed fire, which eventually destroyed most of the aircraft fuselage. The firefighting/extinguishing capability of the foam-equipped ERS vehicles was initially severely hindered by the intense downpour from the thunderstorm, which caused dilution of the foam, rendering it less effective against that type of fire.

The aircraft is equipped with eight exit doors and associated evacuation slides. The two left rear exits were not opened due to the fire observed in that area immediately after the aircraft stopped. One right middle exit was opened, but was closed after the slide deflated after it came into contact with aircraft wreckage. One left exit was opened, but the slide did not deploy. The remaining four exits were commanded open by flight attendants, although the left forward slide was damaged. Many passengers took carry-on luggage with them as they evacuated the aircraft. The complete evacuation was effected in less than two minutes.

Aircraft Systems

No significant anomalies of the aircraft systems have been found to date. Review of DFDR data has not revealed any system malfunctions. No problems were detected with the flight controls, spoilers, tires and brakes, or thrust reversers, based on a physical examination of the wreckage combined with a follow-up detailed DFDR review of parameters. The flight controls functioned as expected, spoilers were deployed on touchdown, the tires and braking system worked as per design, and the thrust reversers were found in the deployed position. Brake assemblies were pressure-tested, and more detailed teardown work was completed at the Messier-Bugatti-Goodrich facility in Troy, Ohio, United States. The main and alternate systems on brakes 2 to 8 were tested at the plant, and all passed the tests. Brake 1 could not be tested because of its damaged post-crash fire condition. This brake was disassembled and nothing was found to indicate that any pre-existing condition was present that would result in a failure or reduced capability of this unit.

Investigation Plan

In the coming months, the investigation team will analyze this accident and other previous occurrences that have similar characteristics to better understand all the contributing factors at play in this accident. The normal TSB procedure during this analysis phase is to look at the man, machine and environment interface to determine whether these factors contributed to the accident. The investigation team continues to be supported by the BEA, the NTSB, and other observers.

When the investigation team's draft report is complete, it will be reviewed and approved by the Director, Air Investigations. The draft report will then be submitted to the Board for its approval and released as a confidential draft report to designated reviewers. The Board will consider the representations of the designated reviewers, and amend the report, if required. At the end of this process, the Board will issue the final investigation report to the public.

If at any time during an investigation, the TSB identifies a safety deficiency, it will issue a safety communication as quickly as possible to the government department and transportation industry entity best able to take safety action to mitigate the identified risks.


1.   All times are in eastern daylight time (Coordinated Universal Time minus four hours).